AMERICAN HEALTH CARE ACT OF 2017; Congressional Record Vol. 163, No. 52
(House of Representatives - March 24, 2017)

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[Pages H2393-H2441]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




                    AMERICAN HEALTH CARE ACT OF 2017

  Mrs. BLACK. Mr. Speaker, pursuant to House Resolution 228, I call up 
the bill (H.R. 1628) to provide for reconciliation pursuant to title II 
of the concurrent resolution on the budget for fiscal year 2017, and 
ask for its immediate consideration.
  The Clerk read the title of the bill.
  The SPEAKER pro tempore (Mr. Simpson). Pursuant to House Resolution 
228, the amendments specified in section 2 of House Resolution 228 
shall be considered as adopted, and the bill, as amended, is considered 
read.
  The text of the bill, as amended, is as follows:

                               H.R. 1628

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``American Health Care Act of 
     2017''.

     SEC. 2. TABLE OF CONTENTS.

       The table of contents of this Act is as follows:

Sec. 1. Short title.
Sec. 2. Table of contents.

                      TITLE I--ENERGY AND COMMERCE

          Subtitle A--Patient Access to Public Health Programs

Sec. 101. The Prevention and Public Health Fund.
Sec. 102. Community health center program.
Sec. 103. Federal payments to States.

                Subtitle B--Medicaid Program Enhancement

Sec. 111. Repeal of Medicaid provisions.
Sec. 112. Repeal of Medicaid expansion.
Sec. 113. Elimination of DSH cuts.
Sec. 114. Reducing State Medicaid costs.
Sec. 115. Safety net funding for non-expansion States.
Sec. 116. Providing incentives for increased frequency of eligibility 
              redeterminations.

        Subtitle C--Per Capita Allotment for Medical Assistance

Sec. 121. Per capita allotment for medical assistance.

    Subtitle D--Patient Relief and Health Insurance Market Stability

Sec. 131. Repeal of cost-sharing subsidy.
Sec. 132. Patient and State Stability Fund.
Sec. 133. Continuous health insurance coverage incentive.
Sec. 134. Increasing coverage options.
Sec. 135. Change in permissible age variation in health insurance 
              premium rates.

                 TITLE II--COMMITTEE ON WAYS AND MEANS

      Subtitle A--Repeal and Replace of Health-Related Tax Policy

Sec. 201. Recapture excess advance payments of premium tax credits.
Sec. 202. Additional modifications to premium tax credit.
Sec. 203. Premium tax credit.
Sec. 204. Small business tax credit.
Sec. 205. Individual mandate.
Sec. 206. Employer mandate.
Sec. 207. Repeal of the tax on employee health insurance premiums and 
              health plan benefits.
Sec. 208. Repeal of tax on over-the-counter medications.
Sec. 209. Repeal of increase of tax on health savings accounts.
Sec. 210. Repeal of limitations on contributions to flexible spending 
              accounts.
Sec. 211. Repeal of medical device excise tax.
Sec. 212. Repeal of elimination of deduction for expenses allocable to 
              medicare part D subsidy.
Sec. 213. Repeal of increase in income threshold for determining 
              medical care deduction.
Sec. 214. Repeal of Medicare tax increase.
Sec. 215. Refundable tax credit for health insurance coverage.
Sec. 216. Maximum contribution limit to health savings account 
              increased to amount of deductible and out-of-pocket 
              limitation.
Sec. 217. Allow both spouses to make catch-up contributions to the same 
              health savings account.
Sec. 218. Special rule for certain medical expenses incurred before 
              establishment of health savings account.

              Subtitle B--Repeal of Certain Consumer Taxes

Sec. 221. Repeal of tax on prescription medications.
Sec. 222. Repeal of health insurance tax.

                   Subtitle C--Repeal of Tanning Tax

Sec. 231. Repeal of tanning tax.

             Subtitle D--Remuneration From Certain Insurers

Sec. 241. Remuneration from certain insurers.

            Subtitle E--Repeal of Net Investment Income Tax

Sec. 251. Repeal of net investment income tax.

                      TITLE I--ENERGY AND COMMERCE

          Subtitle A--Patient Access to Public Health Programs

     SEC. 101. THE PREVENTION AND PUBLIC HEALTH FUND.

       (a) In General.--Subsection (b) of section 4002 of the 
     Patient Protection and Affordable Care Act (42 U.S.C. 300u-
     11), as amended by

[[Page H2394]]

     section 5009 of the 21st Century Cures Act, is amended--
       (1) in paragraph (2), by adding ``and'' at the end;
       (2) in paragraph (3)--
       (A) by striking ``each of fiscal years 2018 and 2019'' and 
     inserting ``fiscal year 2018''; and
       (B) by striking the semicolon at the end and inserting a 
     period; and
       (3) by striking paragraphs (4) through (8).
       (b) Rescission of Unobligated Funds.--Of the funds made 
     available by such section 4002, the unobligated balance at 
     the end of fiscal year 2018 is rescinded.

     SEC. 102. COMMUNITY HEALTH CENTER PROGRAM.

       Effective as if included in the enactment of the Medicare 
     Access and CHIP Reauthorization Act of 2015 (Public Law 114-
     10, 129 Stat. 87), paragraph (1) of section 221(a) of such 
     Act is amended by inserting ``, and an additional 
     $422,000,000 for fiscal year 2017'' after ``2017''.

     SEC. 103. FEDERAL PAYMENTS TO STATES.

       (a) In General.--Notwithstanding section 504(a), 
     1902(a)(23), 1903(a), 2002, 2005(a)(4), 2102(a)(7), or 
     2105(a)(1) of the Social Security Act (42 U.S.C. 704(a), 
     1396a(a)(23), 1396b(a), 1397a, 1397d(a)(4), 1397bb(a)(7), 
     1397ee(a)(1)), or the terms of any Medicaid waiver in effect 
     on the date of enactment of this Act that is approved under 
     section 1115 or 1915 of the Social Security Act (42 U.S.C. 
     1315, 1396n), for the 1-year period beginning on the date of 
     the enactment of this Act, no Federal funds provided from a 
     program referred to in this subsection that is considered 
     direct spending for any year may be made available to a State 
     for payments to a prohibited entity, whether made directly to 
     the prohibited entity or through a managed care organization 
     under contract with the State.
       (b) Definitions.--In this section:
       (1) Prohibited entity.--The term ``prohibited entity'' 
     means an entity, including its affiliates, subsidiaries, 
     successors, and clinics--
       (A) that, as of the date of enactment of this Act--
       (i) is an organization described in section 501(c)(3) of 
     the Internal Revenue Code of 1986 and exempt from tax under 
     section 501(a) of such Code;
       (ii) is an essential community provider described in 
     section 156.235 of title 45, Code of Federal Regulations (as 
     in effect on the date of enactment of this Act), that is 
     primarily engaged in family planning services, reproductive 
     health, and related medical care; and
       (iii) provides for abortions, other than an abortion--

       (I) if the pregnancy is the result of an act of rape or 
     incest; or
       (II) in the case where a woman suffers from a physical 
     disorder, physical injury, or physical illness that would, as 
     certified by a physician, place the woman in danger of death 
     unless an abortion is performed, including a life-endangering 
     physical condition caused by or arising from the pregnancy 
     itself; and

       (B) for which the total amount of Federal and State 
     expenditures under the Medicaid program under title XIX of 
     the Social Security Act in fiscal year 2014 made directly to 
     the entity and to any affiliates, subsidiaries, successors, 
     or clinics of the entity, or made to the entity and to any 
     affiliates, subsidiaries, successors, or clinics of the 
     entity as part of a nationwide health care provider network, 
     exceeded $350,000,000.
       (2) Direct spending.--The term ``direct spending'' has the 
     meaning given that term under section 250(c) of the Balanced 
     Budget and Emergency Deficit Control Act of 1985 (2 U.S.C. 
     900(c)).

                Subtitle B--Medicaid Program Enhancement

     SEC. 111. REPEAL OF MEDICAID PROVISIONS.

       The Social Security Act is amended--
       (1) in section 1902 (42 U.S.C. 1396a)--
       (A) in subsection (a)(47)(B), by inserting ``and provided 
     that any such election shall cease to be effective on January 
     1, 2020, and no such election shall be made after that date'' 
     before the semicolon at the end; and
       (B) in subsection (l)(2)(C), by inserting ``and ending 
     December 31, 2019,'' after ``January 1, 2014,'';
       (2) in section 1915(k)(2) (42 U.S.C. 1396n(k)(2)), by 
     striking ``during the period described in paragraph (1)'' and 
     inserting ``on or after the date referred to in paragraph (1) 
     and before January 1, 2020''; and
       (3) in section 1920(e) (42 U.S.C. 1396r-1(e)), by striking 
     ``under clause (i)(VIII), clause (i)(IX), or clause (ii)(XX) 
     of subsection (a)(10)(A)'' and inserting ``under clause 
     (i)(VIII) or clause (ii)(XX) of section 1902(a)(10)(A) before 
     January 1, 2020, section 1902(a)(10)(A)(i)(IX),''.

     SEC. 112. REPEAL OF MEDICAID EXPANSION.

       (a) In General.--Title XIX of the Social Security Act (42 
     U.S.C. 1396 et seq.) is amended--
       (1) in section 1902 (42 U.S.C. 1396a)--
       (A) in subsection (a)(10)(A)--
       (i) in clause (i)(VIII), by inserting ``and ending December 
     31, 2019,'' after ``2014,'';
       (ii) in clause (ii)(XX), by inserting ``and ending December 
     31, 2017,'' after ``2014,''; and
       (iii) in clause (ii), by adding at the end the following 
     new subclause:
       ``(XXIII) beginning January 1, 2020--

       ``(aa) who are expansion enrollees (as defined in 
     subsection (nn)(1)); or
       ``(bb) who are grandfathered expansion enrollees (as 
     defined in subsection (nn)(2));''; and

       (B) by adding at the end the following new subsection:
       ``(nn) Expansion Enrollees.--In this title:
       ``(1) In general.--The term `expansion enrollee' means an 
     individual--
       ``(A) who is under 65 years of age;
       ``(B) who is not pregnant;
       ``(C) who is not entitled to, or enrolled for, benefits 
     under part A of title XVIII, or enrolled for benefits under 
     part B of title XVIII;
       ``(D) who is not described in any of subclauses (I) through 
     (VII) of subsection (a)(10)(A)(i); and
       ``(E) whose income (as determined under subsection (e)(14)) 
     does not exceed 133 percent of the poverty line (as defined 
     in section 2110(c)(5)) applicable to a family of the size 
     involved.
       ``(2) Grandfathered expansion enrollees.--The term 
     `grandfathered expansion enrollee' means an expansion 
     enrollee who--
       ``(A) was enrolled under the State plan under this title 
     (or under a waiver of such plan) as of December 31, 2019; and
       ``(B) does not have a break in eligibility for medical 
     assistance under such State plan (or waiver) for more than 
     one month after such date.
       ``(3) Application of related provisions.--Any reference in 
     subsection (a)(10)(G), (k), or (gg) of this section or in 
     section 1903, 1905(a), 1920(e), or 1937(a)(1)(B) to 
     individuals described in subclause (VIII) of subsection 
     (a)(10)(A)(i) shall be deemed to include a reference to 
     expansion enrollees (including grandfathered expansion 
     enrollees).''; and
       (2) in section 1905 (42 U.S.C. 1396d)--
       (A) in subsection (y)(1), in the matter preceding 
     subparagraph (A)--
       (i) by inserting ``and that has elected to cover newly 
     eligible individuals before March 1, 2017'' after ``that is 
     one of the 50 States or the District of Columbia''; and
       (ii) by inserting after ``subclause (VIII) of section 
     1902(a)(10)(A)(i)'' the following: ``who, for periods after 
     December 31, 2019, are grandfathered expansion enrollees (as 
     defined in section 1902(nn)(2))''; and
       (B) in subsection (z)(2)--
       (i) in subparagraph (A), by inserting after ``section 
     1937'' the following: ``and, for periods after December 31, 
     2019, who are grandfathered expansion enrollees (as defined 
     in section 1902(nn)(2))''; and
       (ii) in subparagraph (B)(ii)--

       (I) in subclause (III), by adding ``and'' at the end; and
       (II) by striking subclauses (IV), (V), and (VI) and 
     inserting the following new subclause:

       ``(IV) 2017 and each subsequent year is 80 percent.''.
       (b) Sunset of Essential Health Benefits Requirement.--
     Section 1937(b)(5) of the Social Security Act (42 U.S.C. 
     1396u-7(b)(5)) is amended by adding at the end the following: 
     ``This paragraph shall not apply after December 31, 2019.''.

     SEC. 113. ELIMINATION OF DSH CUTS.

       Section 1923(f) of the Social Security Act (42 U.S.C. 
     1396r-4(f)) is amended--
       (1) in paragraph (7)--
       (A) in subparagraph (A)--
       (i) in clause (i)--

       (I) in the matter preceding subclause (I), by striking 
     ``2025'' and inserting ``2019''; and

       (ii) in clause (ii)--

       (I) in subclause (I), by adding ``and'' at the end;
       (II) in subclause (II), by striking the semicolon at the 
     end and inserting a period; and
       (III) by striking subclauses (III) through (VIII); and

       (B) by adding at the end the following new subparagraph:
       ``(C) Exemption from reduction for non-expansion states.--
       ``(i) In general.--In the case of a State that is a non-
     expansion State for a fiscal year, subparagraph (A)(i) shall 
     not apply to the DSH allotment for such State and fiscal 
     year.
       ``(ii) No change in reduction for expansion states.--In the 
     case of a State that is an expansion State for a fiscal year, 
     the DSH allotment for such State and fiscal year shall be 
     determined as if clause (i) did not apply.
       ``(iii) Non-expansion and expansion state defined.--

       ``(I) The term `expansion State' means with respect to a 
     fiscal year, a State that, as of July 1 of the preceding 
     fiscal year, provides for eligibility under clause (i)(VIII) 
     or (ii)(XX) of section 1902(a)(10)(A) for medical assistance 
     under this title (or a waiver of the State plan approved 
     under section 1115).
       ``(II) The term `non-expansion State' means, with respect 
     to a fiscal year, a State that is not an expansion State.''; 
     and

       (2) in paragraph (8), by striking ``fiscal year 2025'' and 
     inserting ``fiscal year 2019''.

     SEC. 114. REDUCING STATE MEDICAID COSTS.

       (a) Letting States Disenroll High Dollar Lottery Winners.--
       (1) In general.--Section 1902 of the Social Security Act 
     (42 U.S.C. 1396a) is amended--
       (A) in subsection (a)(17), by striking ``(e)(14), (e)(14)'' 
     and inserting ``(e)(14), (e)(15)''; and
       (B) in subsection (e)--
       (i) in paragraph (14) (relating to modified adjusted gross 
     income), by adding at the end the following new subparagraph:
       ``(J) Treatment of certain lottery winnings and income 
     received as a lump sum.--
       ``(i) In general.--In the case of an individual who is the 
     recipient of qualified lottery winnings (pursuant to 
     lotteries occurring on or after January 1, 2020) or qualified 
     lump sum income (received on or after such

[[Page H2395]]

     date) and whose eligibility for medical assistance is 
     determined based on the application of modified adjusted 
     gross income under subparagraph (A), a State shall, in 
     determining such eligibility, include such winnings or income 
     (as applicable) as income received--

       ``(I) in the month in which such winnings or income (as 
     applicable) is received if the amount of such winnings or 
     income is less than $80,000;
       ``(II) over a period of 2 months if the amount of such 
     winnings or income (as applicable) is greater than or equal 
     to $80,000 but less than $90,000;
       ``(III) over a period of 3 months if the amount of such 
     winnings or income (as applicable) is greater than or equal 
     to $90,000 but less than $100,000; and
       ``(IV) over a period of 3 months plus 1 additional month 
     for each increment of $10,000 of such winnings or income (as 
     applicable) received, not to exceed a period of 120 months 
     (for winnings or income of $1,260,000 or more), if the amount 
     of such winnings or income is greater than or equal to 
     $100,000.

       ``(ii) Counting in equal installments.--For purposes of 
     subclauses (II), (III), and (IV) of clause (i), winnings or 
     income to which such subclause applies shall be counted in 
     equal monthly installments over the period of months 
     specified under such subclause.
       ``(iii) Hardship exemption.--An individual whose income, by 
     application of clause (i), exceeds the applicable eligibility 
     threshold established by the State, may continue to be 
     eligible for medical assistance to the extent that the State 
     determines, under procedures established by the State under 
     the State plan (or in the case of a waiver of the plan under 
     section 1115, incorporated in such waiver), or as otherwise 
     established by such State in accordance with such standards 
     as may be specified by the Secretary, that the denial of 
     eligibility of the individual would cause an undue medical or 
     financial hardship as determined on the basis of criteria 
     established by the Secretary.
       ``(iv) Notifications and assistance required in case of 
     loss of eligibility.--A State shall, with respect to an 
     individual who loses eligibility for medical assistance under 
     the State plan (or a waiver of such plan) by reason of clause 
     (i), before the date on which the individual loses such 
     eligibility, inform the individual of the date on which the 
     individual would no longer be considered ineligible by reason 
     of such clause to receive medical assistance under the State 
     plan or under any waiver of such plan and the date on which 
     the individual would be eligible to reapply to receive such 
     medical assistance.
       ``(v) Qualified lottery winnings defined.--In this 
     subparagraph, the term `qualified lottery winnings' means 
     winnings from a sweepstakes, lottery, or pool described in 
     paragraph (3) of section 4402 of the Internal Revenue Code of 
     1986 or a lottery operated by a multistate or 
     multijurisdictional lottery association, including amounts 
     awarded as a lump sum payment.
       ``(vi) Qualified lump sum income defined.--In this 
     subparagraph, the term `qualified lump sum income' means 
     income that is received as a lump sum from one of the 
     following sources:

       ``(I) Monetary winnings from gambling (as defined by the 
     Secretary and including monetary winnings from gambling 
     activities described in section 1955(b)(4) of title 18, 
     United States Code).
       ``(II) Income received as liquid assets from the estate (as 
     defined in section 1917(b)(4)) of a deceased individual.''; 
     and

       (ii) by striking ``(14) Exclusion'' and inserting ``(15) 
     Exclusion''.
       (2) Rules of construction.--
       (A) Interception of lottery winnings allowed.--Nothing in 
     the amendment made by paragraph (1)(B)(i) shall be construed 
     as preventing a State from intercepting the State lottery 
     winnings awarded to an individual in the State to recover 
     amounts paid by the State under the State Medicaid plan under 
     title XIX of the Social Security Act for medical assistance 
     furnished to the individual.
       (B) Applicability limited to eligibility of recipient of 
     lottery winnings or lump sum income.--Nothing in the 
     amendment made by paragraph (1)(B)(i) shall be construed, 
     with respect to a determination of household income for 
     purposes of a determination of eligibility for medical 
     assistance under the State plan under title XIX of the Social 
     Security Act (42 U.S.C. 1396 et seq.) (or a waiver of such 
     plan) made by applying modified adjusted gross income under 
     subparagraph (A) of section 1902(e)(14) of such Act (42 
     U.S.C. 1396a(e)(14)), as limiting the eligibility for such 
     medical assistance of any individual that is a member of the 
     household other than the individual (or the individual's 
     spouse) who received qualified lottery winnings or qualified 
     lump-sum income (as defined in subparagraph (J) of such 
     section 1902(e)(14), as added by paragraph (1)(B)(i) of this 
     subsection).
       (b) Repeal of Retroactive Eligibility.--
       (1) In general.--
       (A) State plan requirements.--Section 1902(a)(34) of the 
     Social Security Act (42 U.S.C. 1396a(a)(34)) is amended by 
     striking ``in or after the third month before the month in 
     which he made application'' and inserting ``in or after the 
     month in which the individual made application''.
       (B) Definition of medical assistance.--Section 1905(a) of 
     the Social Security Act (42 U.S.C. 1396d(a)) is amended by 
     striking ``in or after the third month before the month in 
     which the recipient makes application for assistance'' and 
     inserting ``in or after the month in which the recipient 
     makes application for assistance''.
       (2) Effective date.--The amendments made by paragraph (1) 
     shall apply to medical assistance with respect to individuals 
     whose eligibility for such assistance is based on an 
     application for such assistance made (or deemed to be made) 
     on or after October 1, 2017.
       (c) Updating Allowable Home Equity Limits in Medicaid.--
       (1) In general.--Section 1917(f)(1) of the Social Security 
     Act (42 U.S.C. 1396p(f)(1)) is amended--
       (A) in subparagraph (A), by striking ``subparagraphs (B) 
     and (C)'' and inserting ``subparagraph (B)'';
       (B) by striking subparagraph (B);
       (C) by redesignating subparagraph (C) as subparagraph (B); 
     and
       (D) in subparagraph (B), as so redesignated, by striking 
     ``dollar amounts specified in this paragraph'' and inserting 
     ``dollar amount specified in subparagraph (A)''.
       (2) Effective date.--
       (A) In general.--The amendments made by paragraph (1) shall 
     apply with respect to eligibility determinations made after 
     the date that is 180 days after the date of the enactment of 
     this section.
       (B) Exception for state legislation.--In the case of a 
     State plan under title XIX of the Social Security Act that 
     the Secretary of Health and Human Services determines 
     requires State legislation in order for the respective plan 
     to meet any requirement imposed by amendments made by this 
     subsection, the respective plan shall not be regarded as 
     failing to comply with the requirements of such title solely 
     on the basis of its failure to meet such an additional 
     requirement before the first day of the first calendar 
     quarter beginning after the close of the first regular 
     session of the State legislature that begins after the date 
     of the enactment of this Act. For purposes of the previous 
     sentence, in the case of a State that has a 2-year 
     legislative session, each year of the session shall be 
     considered to be a separate regular session of the State 
     legislature.

     SEC. 115. SAFETY NET FUNDING FOR NON-EXPANSION STATES.

       Title XIX of the Social Security Act is amended by 
     inserting after section 1923 (42 U.S.C. 1396r-4) the 
     following new section:


  ``adjustment in payment for services of safety net providers in non-
                            expansion states

       ``Sec. 1923A.  (a) In General.--Subject to the limitations 
     of this section, for each year during the period beginning 
     with fiscal year 2018 and ending with fiscal year 2022, each 
     State that is one of the 50 States or the District of 
     Columbia and that, as of July 1 of the preceding fiscal year, 
     did not provide for eligibility under clause (i)(VIII) or 
     (ii)(XX) of section 1902(a)(10)(A) for medical assistance 
     under this title (or a waiver of the State plan approved 
     under section 1115) (each such State or District referred to 
     in this section for the fiscal year as a `non-expansion 
     State') may adjust the payment amounts otherwise provided 
     under the State plan under this title (or a waiver of such 
     plan) to health care providers that provide health care 
     services to individuals enrolled under this title (in this 
     section referred to as `eligible providers') so long as the 
     payment adjustment to such an eligible provider does not 
     exceed the provider's costs in furnishing health care 
     services (as determined by the Secretary and net of payments 
     under this title, other than under this section, and by 
     uninsured patients) to individuals who either are eligible 
     for medical assistance under the State plan (or under a 
     waiver of such plan) or have no health insurance or health 
     plan coverage for such services.
       ``(b) Increase in Applicable FMAP.--Notwithstanding section 
     1905(b), the Federal medical assistance percentage applicable 
     with respect to expenditures attributable to a payment 
     adjustment under subsection (a) for which payment is 
     permitted under subsection (c) shall be equal to--
       ``(1) 100 percent for calendar quarters in fiscal years 
     2018, 2019, 2020, and 2021; and
       ``(2) 95 percent for calendar quarters in fiscal year 2022.
       ``(c) Annual Allotment Limitation.--Payment under section 
     1903(a) shall not be made to a State with respect to any 
     payment adjustment made under this section for all calendar 
     quarters in a fiscal year in excess of the $2,000,000,000 
     multiplied by the ratio of--
       ``(1) the population of the State with income below 138 
     percent of the poverty line in 2015 (as determined based the 
     table entitled `Health Insurance Coverage Status and Type by 
     Ratio of Income to Poverty Level in the Past 12 Months by 
     Age' for the universe of the civilian noninstitutionalized 
     population for whom poverty status is determined based on the 
     2015 American Community Survey 1-Year Estimates, as published 
     by the Bureau of the Census), to
       ``(2) the sum of the populations under paragraph (1) for 
     all non-expansion States.
       ``(d) Disqualification in Case of State Coverage 
     Expansion.--If a State is a non-expansion for a fiscal year 
     and provides eligibility for medical assistance described in 
     subsection (a) during the fiscal year, the State shall no 
     longer be treated as a non-expansion State under this section 
     for any subsequent fiscal years.''.

     SEC. 116. PROVIDING INCENTIVES FOR INCREASED FREQUENCY OF 
                   ELIGIBILITY REDETERMINATIONS.

       (a) In General.--Section 1902(e)(14) of the Social Security 
     Act (42 U.S.C. 1396a(e)(14))

[[Page H2396]]

     (relating to modified adjusted gross income), as amended by 
     section 114(a)(1), is further amended by adding at the end 
     the following:
       ``(K) Frequency of eligibility redeterminations.--Beginning 
     on October 1, 2017, and notwithstanding subparagraph (H), in 
     the case of an individual whose eligibility for medical 
     assistance under the State plan under this title (or a waiver 
     of such plan) is determined based on the application of 
     modified adjusted gross income under subparagraph (A) and who 
     is so eligible on the basis of clause (i)(VIII) or clause 
     (ii)(XX) of subsection (a)(10)(A), a State shall redetermine 
     such individual's eligibility for such medical assistance no 
     less frequently than once every 6 months.''.
       (b) Increased Administrative Matching Percentage.--For each 
     calendar quarter during the period beginning on October 1, 
     2017, and ending on December 31, 2019, the Federal matching 
     percentage otherwise applicable under section 1903(a) of the 
     Social Security Act (42 U.S.C. 1396b(a)) with respect to 
     State expenditures during such quarter that are attributable 
     to meeting the requirement of section 1902(e)(14) (relating 
     to determinations of eligibility using modified adjusted 
     gross income) of such Act shall be increased by 5 percentage 
     points with respect to State expenditures attributable to 
     activities carried out by the State (and approved by the 
     Secretary) to increase the frequency of eligibility 
     redeterminations required by subparagraph (K) of such section 
     (relating to eligibility redeterminations made on a 6-month 
     basis) (as added by subsection (a)).

     SEC. 117. PERMITTING STATES TO APPLY A WORK REQUIREMENT FOR 
                   NONDISABLED, NONELDERLY, NONPREGNANT ADULTS 
                   UNDER MEDICAID.

       (a) In General.--Section 1902 of the Social Security Act 
     (42 U.S.C. 1396a), as previously amended, is further amended 
     by adding at the end the following new subsection:
       ``(oo) Work Requirement Option for Nondisabled, Nonelderly, 
     Nonpregnant Adults.--
       ``(1) In general.--Beginning October 1, 2017, subject to 
     paragraph (3), a State may elect to condition medical 
     assistance to a nondisabled, nonelderly, nonpregnant 
     individual under this title upon such an individual's 
     satisfaction of a work requirement (as defined in paragraph 
     (2)).
       ``(2) Work requirement defined.--In this section, the term 
     `work requirement' means, with respect to an individual, the 
     individual's participation in work activities (as defined in 
     section 407(d)) for such period of time as determined by the 
     State, and as directed and administered by the State.
       ``(3) Required exceptions.--States administering a work 
     requirement under this subsection may not apply such 
     requirement to--
       ``(A) a woman during pregnancy through the end of the month 
     in which the 60-day period (beginning on the last day of her 
     pregnancy) ends;
       ``(B) an individual who is under 19 years of age;
       ``(C) an individual who is the only parent or caretaker 
     relative in the family of a child who has not attained 6 
     years of age or who is the only parent or caretaker of a 
     child with disabilities; or
       ``(D) an individual who is married or a head of household 
     and has not attained 20 years of age and who--
       ``(i) maintains satisfactory attendance at secondary school 
     or the equivalent; or
       ``(ii) participates in education directly related to 
     employment.''.
       (b) Increase in Matching Rate for Implementation.--Section 
     1903 of the Social Security Act (42 U.S.C. 1396b) is amended 
     by adding at the end the following:
       ``(aa) The Federal matching percentage otherwise applicable 
     under subsection (a) with respect to State administrative 
     expenditures during a calendar quarter for which the State 
     receives payment under such subsection shall, in addition to 
     any other increase to such Federal matching percentage, be 
     increased for such calendar quarter by 5 percentage points 
     with respect to State expenditures attributable to activities 
     carried out by the State (and approved by the Secretary) to 
     implement subsection (oo) of section 1902.''.

        Subtitle C--Per Capita Allotment for Medical Assistance

     SEC. 121. PER CAPITA ALLOTMENT FOR MEDICAL ASSISTANCE.

       Title XIX of the Social Security Act is amended--
       (1) in section 1903 (42 U.S.C. 1396b)--
       (A) in subsection (a), in the matter before paragraph (1), 
     by inserting ``and section 1903A(a)'' after ``except as 
     otherwise provided in this section''; and
       (B) in subsection (d)(1), by striking ``to which'' and 
     inserting ``to which, subject to section 1903A(a),''; and
       (2) by inserting after such section 1903 the following new 
     section:

     ``SEC. 1903A. PER CAPITA-BASED CAP ON PAYMENTS FOR MEDICAL 
                   ASSISTANCE.

       ``(a) Application of Per Capita Cap on Payments for Medical 
     Assistance Expenditures.--
       ``(1) In general.--If a State has excess aggregate medical 
     assistance expenditures (as defined in paragraph (2)) for a 
     fiscal year (beginning with fiscal year 2020), the amount of 
     payment to the State under section 1903(a)(1) for each 
     quarter in the following fiscal year shall be reduced by \1/
     4\ of the excess aggregate medical assistance payments (as 
     defined in paragraph (3)) for that previous fiscal year. In 
     this section, the term `State' means only the 50 States and 
     the District of Columbia.
       ``(2) Excess aggregate medical assistance expenditures.--In 
     this subsection, the term `excess aggregate medical 
     assistance expenditures' means, for a State for a fiscal 
     year, the amount (if any) by which--
       ``(A) the amount of the adjusted total medical assistance 
     expenditures (as defined in subsection (b)(1)) for the State 
     and fiscal year; exceeds
       ``(B) the amount of the target total medical assistance 
     expenditures (as defined in subsection (c)) for the State and 
     fiscal year.
       ``(3) Excess aggregate medical assistance payments.--In 
     this subsection, the term `excess aggregate medical 
     assistance payments' means, for a State for a fiscal year, 
     the product of--
       ``(A) the excess aggregate medical assistance expenditures 
     (as defined in paragraph (2)) for the State for the fiscal 
     year; and
       ``(B) the Federal average medical assistance matching 
     percentage (as defined in paragraph (4)) for the State for 
     the fiscal year.
       ``(4) Federal average medical assistance matching 
     percentage.--In this subsection, the term `Federal average 
     medical assistance matching percentage' means, for a State 
     for a fiscal year, the ratio (expressed as a percentage) of--
       ``(A) the amount of the Federal payments that would be made 
     to the State under section 1903(a)(1) for medical assistance 
     expenditures for calendar quarters in the fiscal year if 
     paragraph (1) did not apply; to
       ``(B) the amount of the medical assistance expenditures for 
     the State and fiscal year.
       ``(b) Adjusted Total Medical Assistance Expenditures.--
     Subject to subsection (g), the following shall apply:
       ``(1) In general.--In this section, the term `adjusted 
     total medical assistance expenditures' means, for a State--
       ``(A) for fiscal year 2016, the product of--
       ``(i) the amount of the medical assistance expenditures (as 
     defined in paragraph (2)) for the State and fiscal year, 
     reduced by the amount of any excluded expenditures (as 
     defined in paragraph (3)) for the State and fiscal year 
     otherwise included in such medical assistance expenditures; 
     and
       ``(ii) the 1903A FY16 population percentage (as defined in 
     paragraph (4)) for the State; or
       ``(B) for fiscal year 2019 or a subsequent fiscal year, the 
     amount of the medical assistance expenditures (as defined in 
     paragraph (2)) for the State and fiscal year that is 
     attributable to 1903A enrollees, reduced by the amount of any 
     excluded expenditures (as defined in paragraph (3)) for the 
     State and fiscal year otherwise included in such medical 
     assistance expenditures and includes non-DSH supplemental 
     payments (as defined in subsection (d)(4)(A)(ii)) and 
     payments described in subsection (d)(4)(A)(iii) but shall not 
     be construed as including any expenditures attributable to 
     the program under section 1928. In applying subparagraph (B), 
     non-DSH supplemental payments (as defined in subsection 
     (d)(4)(A)(ii)) and payments described in subsection 
     (d)(4)(A)(iii) shall be treated as fully attributable to 
     1903A enrollees.
       ``(2) Medical assistance expenditures.--In this section, 
     the term `medical assistance expenditures' means, for a State 
     and fiscal year, the medical assistance payments as reported 
     by medical service category on the Form CMS-64 quarterly 
     expense report (or successor to such a report form, and 
     including enrollment data and subsequent adjustments to any 
     such report, in this section referred to collectively as a 
     `CMS-64 report') for which payment is (or may otherwise be) 
     made pursuant to section 1903(a)(1).
       ``(3) Excluded expenditures.--In this section, the term 
     `excluded expenditures' means, for a State and fiscal year, 
     expenditures under the State plan (or under a waiver of such 
     plan) that are attributable to any of the following:
       ``(A) DSH.--Payment adjustments made for disproportionate 
     share hospitals under section 1923.
       ``(B) Medicare cost-sharing.--Payments made for medicare 
     cost-sharing (as defined in section 1905(p)(3)).
       ``(C) Safety net provider payment adjustments in non-
     expansion states.--Payment adjustments under subsection (a) 
     of section 1923A for which payment is permitted under 
     subsection (c) of such section.
       ``(4) 1903A fy 16 population percentage.--In this 
     subsection, the term `1903A FY16 population percentage' 
     means, for a State, the Secretary's calculation of the 
     percentage of the actual medical assistance expenditures, as 
     reported by the State on the CMS-64 reports for calendar 
     quarters in fiscal year 2016, that are attributable to 1903A 
     enrollees (as defined in subsection (e)(1)).
       ``(c)  Target Total Medical Assistance Expenditures.--
       ``(1) Calculation.--In this section, the term `target total 
     medical assistance expenditures' means, for a State for a 
     fiscal year and subject to paragraph (4), the sum of the 
     products, for each of the 1903A enrollee categories (as 
     defined in subsection (e)(2)), of--
       ``(A) the target per capita medical assistance expenditures 
     (as defined in paragraph (2)) for the enrollee category, 
     State, and fiscal year; and
       ``(B) the number of 1903A enrollees for such enrollee 
     category, State, and fiscal year, as determined under 
     subsection (e)(4).
       ``(2) Target per capita medical assistance expenditures.--
     In this subsection, the term `target per capita medical 
     assistance expenditures' means, for a 1903A enrollee category 
     and State--

[[Page H2397]]

       ``(A) for fiscal year 2020, an amount equal to--
       ``(i) the provisional FY19 target per capita amount for 
     such enrollee category (as calculated under subsection 
     (d)(5)) for the State; increased by
       ``(ii) the applicable annual inflation factor (as defined 
     in paragraph (3)) for fiscal year 2020; and
       ``(B) for each succeeding fiscal year, an amount equal to--
       ``(i) the target per capita medical assistance expenditures 
     (under subparagraph (A) or this subparagraph) for the 1903A 
     enrollee category and State for the preceding fiscal year, 
     increased by
       ``(ii) the applicable annual inflation factor for that 
     succeeding fiscal year.
       ``(3) Applicable annual inflation factor.--In paragraph 
     (2), the term `applicable annual inflation factor' means, for 
     a fiscal year--
       ``(A) for each of the 1903A enrollee categories described 
     in subparagraphs (C), (D), and (E) of subsection (e)(2), the 
     percentage increase in the medical care component of the 
     consumer price index for all urban consumers (U.S. city 
     average) from September of the previous fiscal year to 
     September of the fiscal year involved; and
       ``(B) for each of the 1903A enrollee categories described 
     in subparagraphs (A) and (B) of subsection (e)(2), the 
     percentage increase described in subparagraph (A) plus 1 
     percentage point.
       ``(4) Decrease in target expenditures for required 
     expenditures by certain political subdivisions.--
       ``(A) In general.--In the case of a State that had a DSH 
     allotment under section 1923(f) for fiscal year 2016 that was 
     more than 6 times the national average of such allotments for 
     all the States for such fiscal year and that requires 
     political subdivisions within the State to contribute funds 
     towards medical assistance or other expenditures under the 
     State plan under this title (or under a waiver of such plan) 
     for a fiscal year (beginning with fiscal year 2020), the 
     target total medical assistance expenditures for such State 
     and fiscal year shall be decreased by the amount that 
     political subdivisions in the State are required to 
     contribute under the plan (or waiver) without reimbursement 
     from the State for such fiscal year, other than contributions 
     described in subparagraph (B).
       ``(B) Exceptions.--The contributions described in this 
     subparagraph are the following:
       ``(i) Contributions required by a State from a political 
     subdivision that, as of the first day of the calendar year in 
     which the fiscal year involved begins--

       ``(I) has a population of more than 5,000,000, as estimated 
     by the Bureau of the Census; and
       ``(II) imposes a local income tax upon its residents.

       ``(ii) Contributions required by a State from a political 
     subdivision for administrative expenses if the State required 
     such contributions from such subdivision without 
     reimbursement from the State as of January 1, 2017.
       ``(d) Calculation of FY19 Provisional Target Amount for 
     Each 1903A Enrollee Category.--Subject to subsection (g), the 
     following shall apply:
       ``(1) Calculation of base amounts for fiscal year 2016.--
     For each State the Secretary shall calculate (and provide 
     notice to the State not later than April 1, 2018, of) the 
     following:
       ``(A) The amount of the adjusted total medical assistance 
     expenditures (as defined in subsection (b)(1)) for the State 
     for fiscal year 2016.
       ``(B) The number of 1903A enrollees for the State in fiscal 
     year 2016 (as determined under subsection (e)(4)).
       ``(C) The average per capita medical assistance 
     expenditures for the State for fiscal year 2016 equal to--
       ``(i) the amount calculated under subparagraph (A); divided 
     by
       ``(ii) the number calculated under subparagraph (B).
       ``(2) Fiscal year 2019 average per capita amount based on 
     inflating the fiscal year 2016 amount to fiscal year 2019 by 
     cpi-medical.--The Secretary shall calculate a fiscal year 
     2019 average per capita amount for each State equal to--
       ``(A) the average per capita medical assistance 
     expenditures for the State for fiscal year 2016 (calculated 
     under paragraph (1)(C)); increased by
       ``(B) the percentage increase in the medical care component 
     of the consumer price index for all urban consumers (U.S. 
     city average) from September, 2016 to September, 2019.
       ``(3) Aggregate and average expenditures per capita for 
     fiscal year 2019.--The Secretary shall calculate for each 
     State the following:
       ``(A) The amount of the adjusted total medical assistance 
     expenditures (as defined in subsection (b)(1)) for the State 
     for fiscal year 2019. 
       ``(B) The number of 1903A enrollees for the State in fiscal 
     year 2019 (as determined under subsection (e)(4)).
       ``(4) Per capita expenditures for fiscal year 2019 for each 
     1903a enrollee category.--The Secretary shall calculate (and 
     provide notice to each State not later than January 1, 2020, 
     of) the following:
       ``(A)(i) For each 1903A enrollee category, the amount of 
     the adjusted total medical assistance expenditures (as 
     defined in subsection (b)(1)) for the State for fiscal year 
     2019 for individuals in the enrollee category, calculated by 
     excluding from medical assistance expenditures those 
     expenditures attributable to expenditures described in clause 
     (iii) or non-DSH supplemental expenditures (as defined in 
     clause (ii)).
       ``(ii) In this paragraph, the term `non-DSH supplemental 
     expenditure' means a payment to a provider under the State 
     plan (or under a waiver of the plan) that--
       ``(I) is not made under section 1923;
       ``(II) is not made with respect to a specific item or 
     service for an individual;
       ``(III) is in addition to any payments made to the provider 
     under the plan (or waiver) for any such item or service; and
       ``(IV) complies with the limits for additional payments to 
     providers under the plan (or waiver) imposed pursuant to 
     section 1902(a)(30)(A), including the regulations specifying 
     upper payment limits under the State plan in part 447 of 
     title 42, Code of Federal Regulations (or any successor 
     regulations).
       ``(iii) An expenditure described in this clause is an 
     expenditure that meets the criteria specified in subclauses 
     (I), (II), and (III) of clause (ii) and is authorized under 
     section 1115 for the purposes of funding a delivery system 
     reform pool, uncompensated care pool, a designated state 
     health program, or any other similar expenditure (as defined 
     by the Secretary).
       ``(B) For each 1903A enrollee category, the number of 1903A 
     enrollees for the State in fiscal year 2019 in the enrollee 
     category (as determined under subsection (e)(4)).
       ``(C) For fiscal year 2016, the State's non-DSH 
     supplemental and pool payment percentage is equal to the 
     ratio (expressed as a percentage) of--
       ``(i) the total amount of non-DSH supplemental expenditures 
     (as defined in subparagraph (A)(ii)) and payments described 
     in subparagraph (A)(iii) for the State for fiscal year 2016; 
     to
       ``(ii) the amount described in subsection (b)(1)(A) for the 
     State for fiscal year 2016.
       ``(D) For each 1903A enrollee category an average medical 
     assistance expenditures per capita for the State for fiscal 
     year 2019 for the enrollee category equal to--
       ``(i) the amount calculated under subparagraph (A) for the 
     State, increased by the non-DSH supplemental and pool payment 
     percentage for the State (as calculated under subparagraph 
     (C)); divided by
       ``(ii) the number calculated under subparagraph (B) for the 
     State for the enrollee category.
       ``(5) Provisional fy19 per capita target amount for each 
     1903a enrollee category.--Subject to subsection (f)(2), the 
     Secretary shall calculate for each State a provisional FY19 
     per capita target amount for each 1903A enrollee category 
     equal to the average medical assistance expenditures per 
     capita for the State for fiscal year 2019 (as calculated 
     under paragraph (4)(D)) for such enrollee category multiplied 
     by the ratio of--
       ``(A) the product of--
       ``(i) the fiscal year 2019 average per capita amount for 
     the State, as calculated under paragraph (2); and
       ``(ii) the number of 1903A enrollees for the State in 
     fiscal year 2019, as calculated under paragraph (3)(B); to
       ``(B) the amount of the adjusted total medical assistance 
     expenditures for the State for fiscal year 2019, as 
     calculated under paragraph (3)(A).
       ``(e) 1903A Enrollee; 1903A Enrollee Category.--Subject to 
     subsection (g), for purposes of this section, the following 
     shall apply:
       ``(1) 1903A enrollee.--The term `1903A enrollee' means, 
     with respect to a State and a month and subject to subsection 
     (i)(1)(B), any Medicaid enrollee (as defined in paragraph 
     (3)) for the month, other than such an enrollee who for such 
     month is in any of the following categories of excluded 
     individuals:
       ``(A) CHIP.--An individual who is provided, under this 
     title in the manner described in section 2101(a)(2), child 
     health assistance under title XXI.
       ``(B) IHS.--An individual who receives any medical 
     assistance under this title for services for which payment is 
     made under the third sentence of section 1905(b).
       ``(C) Breast and cervical cancer services eligible 
     individual.--An individual who is entitled to medical 
     assistance under this title only pursuant to section 
     1902(a)(10)(A)(ii)(XVIII).
       ``(D) Partial-benefit enrollees.--An individual who--
       ``(i) is an alien who is entitled to medical assistance 
     under this title only pursuant to section 1903(v)(2);
       ``(ii) is entitled to medical assistance under this title 
     only pursuant to subclause (XII) or (XXI) of section 
     1902(a)(10)(A)(ii) (or pursuant to a waiver that provides 
     only comparable benefits);
       ``(iii) is a dual eligible individual (as defined in 
     section 1915(h)(2)(B)) and is entitled to medical assistance 
     under this title (or under a waiver) only for some or all of 
     medicare cost-sharing (as defined in section 1905(p)(3)); or
       ``(iv) is entitled to medical assistance under this title 
     and for whom the State is providing a payment or subsidy to 
     an employer for coverage of the individual under a group 
     health plan pursuant to section 1906 or section 1906A (or 
     pursuant to a waiver that provides only comparable benefits).
       ``(2) 1903A enrollee category.--The term `1903A enrollee 
     category' means each of the following:

[[Page H2398]]

       ``(A) Elderly.--A category of 1903A enrollees who are 65 
     years of age or older.
       ``(B) Blind and disabled.--A category of 1903A enrollees 
     (not described in the previous subparagraph) who are eligible 
     for medical assistance under this title on the basis of being 
     blind or disabled.
       ``(C) Children.--A category of 1903A enrollees (not 
     described in a previous subparagraph) who are children under 
     19 years of age.
       ``(D) Expansion enrollees.--A category of 1903A enrollees 
     (not described in a previous subparagraph) for whom the 
     amounts expended for medical assistance are subject to an 
     increase or change in the Federal medical assistance 
     percentage under subsection (y) or (z)(2), respectively, of 
     section 1905.
       ``(E) Other nonelderly, nondisabled, non-expansion 
     adults.--A category of 1903A enrollees who are not described 
     in any previous subparagraph.
       ``(3) Medicaid enrollee.--The term `Medicaid enrollee' 
     means, with respect to a State for a month, an individual who 
     is eligible for medical assistance for items or services 
     under this title and enrolled under the State plan (or a 
     waiver of such plan) under this title for the month.
       ``(4) Determination of number of 1903a enrollees.--The 
     number of 1903A enrollees for a State and fiscal year, and, 
     if applicable, for a 1903A enrollee category, is the average 
     monthly number of Medicaid enrollees for such State and 
     fiscal year (and, if applicable, in such category) that are 
     reported through the CMS-64 report under (and subject to 
     audit under) subsection (h).
       ``(f) Special Payment Rules.--
       ``(1) Application in case of research and demonstration 
     projects and other waivers.--In the case of a State with a 
     waiver of the State plan approved under section 1115, section 
     1915, or another provision of this title, this section shall 
     apply to medical assistance expenditures and medical 
     assistance payments under the waiver, in the same manner as 
     if such expenditures and payments had been made under a State 
     plan under this title and the limitations on expenditures 
     under this section shall supersede any other payment 
     limitations or provisions (including limitations based on a 
     per capita limitation) otherwise applicable under such a 
     waiver.
       ``(2) Treatment of states expanding coverage after fiscal 
     year 2016.--In the case of a State that did not provide for 
     medical assistance for the 1903A enrollee category described 
     in subsection (e)(2)(D) during fiscal year 2016 but which 
     provides for such assistance for such category in a 
     subsequent year, the provisional FY19 per capita target 
     amount for such enrollee category under subsection (d)(5) 
     shall be equal to the provisional FY19 per capita target 
     amount for the 1903A enrollee category described in 
     subsection (e)(2)(E).
       ``(3) In case of state failure to report necessary data.--
     If a State for any quarter in a fiscal year (beginning with 
     fiscal year 2019) fails to satisfactorily submit data on 
     expenditures and enrollees in accordance with subsection 
     (h)(1), for such fiscal year and any succeeding fiscal year 
     for which such data are not satisfactorily submitted--
       ``(A) the Secretary shall calculate and apply subsections 
     (a) through (e) with respect to the State as if all 1903A 
     enrollee categories for which such expenditure and enrollee 
     data were not satisfactorily submitted were a single 1903A 
     enrollee category; and
       ``(B) the growth factor otherwise applied under subsection 
     (c)(2)(B) shall be decreased by 1 percentage point.
       ``(g) Recalculation of Certain Amounts for Data Errors.--
     The amounts and percentage calculated under paragraphs (1) 
     and (4)(C) of subsection (d) for a State for fiscal year 
     2016, and the amounts of the adjusted total medical 
     assistance expenditures calculated under subsection (b) and 
     the number of Medicaid enrollees and 1903A enrollees 
     determined under subsection (e)(4) for a State for fiscal 
     year 2016, fiscal year 2019, and any subsequent fiscal year, 
     may be adjusted by the Secretary based upon an appeal (filed 
     by the State in such a form, manner, and time, and containing 
     such information relating to data errors that support such 
     appeal, as the Secretary specifies) that the Secretary 
     determines to be valid, except that any adjustment by the 
     Secretary under this subsection for a State may not result in 
     an increase of the target total medical assistance 
     expenditures exceeding 2 percent.
       ``(h) Required Reporting and Auditing of CMS-64 Data; 
     Transitional Increase in Federal Matching Percentage for 
     Certain Administrative Expenses.--
       ``(1) Reporting.--In addition to the data required on form 
     Group VIII on the CMS-64 report form as of January 1, 2017, 
     in each CMS-64 report required to be submitted (for each 
     quarter beginning on or after October 1, 2018), the State 
     shall include data on medical assistance expenditures within 
     such categories of services and categories of enrollees 
     (including each 1903A enrollee category and each category of 
     excluded individuals under subsection (e)(1)) and the numbers 
     of enrollees within each of such enrollee categories, as the 
     Secretary determines are necessary (including timely guidance 
     published as soon as possible after the date of the enactment 
     of this section) in order to implement this section and to 
     enable States to comply with the requirement of this 
     paragraph on a timely basis.
       ``(2) Auditing.--The Secretary shall conduct for each State 
     an audit of the number of individuals and expenditures 
     reported through the CMS-64 report for fiscal year 2016, 
     fiscal year 2019, and each subsequent fiscal year, which 
     audit may be conducted on a representative sample (as 
     determined by the Secretary).
       ``(3) Temporary increase in federal matching percentage to 
     support improved data reporting systems for fiscal years 2018 
     and 2019.--For amounts expended during calendar quarters 
     beginning on or after October 1, 2017, and before October 1, 
     2019--
       ``(A) the Federal matching percentage applied under section 
     1903(a)(3)(A)(i) shall be increased by 10 percentage points 
     to 100 percent;
       ``(B) the Federal matching percentage applied under section 
     1903(a)(3)(B) shall be increased by 25 percentage points to 
     100 percent; and
       ``(C) the Federal matching percentage applied under section 
     1903(a)(7) shall be increased by 10 percentage points to 60 
     percent but only with respect to amounts expended that are 
     attributable to a State's additional administrative 
     expenditures to implement the data requirements of paragraph 
     (1).
       ``(i) Flexible Block Grant Option for States.--
       ``(1) In general.--In the case of a State that elects the 
     option of applying this subsection for a 10-fiscal-year 
     period (beginning no earlier than fiscal year 2020 and, at 
     the State option, for any succeeding 10-fiscal-year period) 
     and that has a plan approved by the Secretary under paragraph 
     (2) to carry out the option for such period--
       ``(A) the State shall receive, instead of amounts otherwise 
     payable to the State under this title for medical assistance 
     for block grant individuals within the applicable block grant 
     category (as defined in paragraph (6)) for the State during 
     the period in which the election is in effect, the amount 
     specified in paragraph (4);
       ``(B) the previous provisions of this section shall be 
     applied as if--
       ``(i) block grant individuals within the applicable block 
     grant category for the State and period were not section 
     1903A enrollees for each 10-fiscal year period for which the 
     State elects to apply this subsection; and
       ``(ii) if such option is not extended at the end of a 10-
     fiscal-year-period, the per capita limitations under such 
     previous provisions shall again apply after such period and 
     such limitations shall be applied as if the election under 
     this subsection had never taken place;
       ``(C) the payment under this subsection may only be used 
     consistent with the State plan under paragraph (2) for block 
     grant health care assistance (as defined in paragraph (7)); 
     and
       ``(D) with respect to block grant individuals within the 
     applicable block grant category for the State for which block 
     grant health care assistance is made available under this 
     subsection, such assistance shall be instead of medical 
     assistance otherwise provided to the individual under this 
     title.
       ``(2) State plan for administering block grant option.--
       ``(A) In general.--No payment shall be made under this 
     subsection to a State pursuant to an election for a 10-
     fiscal-year period under paragraph (1) unless the State has a 
     plan, approved under subparagraph (B), for such period that 
     specifies--
       ``(i) the applicable block grant category with respect to 
     which the State will apply the option under this subsection 
     for such period;
       ``(ii) the conditions for eligibility of block grant 
     individuals within such applicable block grant category for 
     block grant health care assistance under the option, which 
     shall be instead of other conditions for eligibility under 
     this title, except that in the case of a State that has 
     elected the applicable block grant category described in--

       ``(I) subparagraph (A) of paragraph (6), the plan must 
     provide for eligibility for pregnant women and children 
     required to be provided medical assistance under subsections 
     (a)(10)(A)(i) and (e)(4) of section 1902; or
       ``(II) subparagraph (B) of paragraph (6), the plan must 
     provide for eligibility for pregnant women required to be 
     provided medical assistance under subsection (a)(10)(A)(i); 
     and

       ``(iii) the types of items and services, the amount, 
     duration, and scope of such services, the cost-sharing with 
     respect to such services, and the method for delivery of 
     block grant health care assistance under this subsection, 
     which shall be instead of the such types, amount, duration, 
     and scope, cost-sharing, and methods of delivery for medical 
     assistance otherwise required under this title, except that 
     the plan must provide for assistance for--

       ``(I) hospital care;
       ``(II) surgical care and treatment;
       ``(III) medical care and treatment;
       ``(IV) obstetrical and prenatal care and treatment;
       ``(V) prescribed drugs, medicines, and prosthetic devices;
       ``(VI) other medical supplies and services; and
       ``(VII) health care for children under 18 years of age.

       ``(B) Review and approval.--A plan described in 
     subparagraph (A) shall be deemed approved by the Secretary 
     unless the Secretary determines, within 30 days after the 
     date of the Secretary's receipt of the plan, that the plan is 
     incomplete or actuarially unsound and, with respect to such 
     plan and its implementation under this subsection, the 
     requirements of paragraphs (1), (10)(B), (17), and (23) of 
     section 1902(a) shall not apply.
       ``(3) Amount of block grant funds.--

[[Page H2399]]

       ``(A) For initial fiscal year.--The block grant amount 
     under this paragraph for a State for the initial fiscal year 
     in the first 10-fiscal-year period is equal to the sum of the 
     products (for each applicable block grant category for such 
     State and period) of--
       ``(i) the target per capita medical assistance expenditures 
     for such State for such fiscal year (under subsection 
     (c)(2));
       ``(ii) the number of 1903A enrollees for such category and 
     State for fiscal year 2019, as determined under subsection 
     (e)(4); and
       ``(iii) the Federal average medical assistance matching 
     percentage (as defined in subsection (a)(4)) for the State 
     for fiscal year 2019.
       ``(B) For any subsequent fiscal year.--The block grant 
     amount under this paragraph for a State for each succeeding 
     fiscal year (in any 10-fiscal-year period) is equal to the 
     block grant amount under subparagraph (A) (or this 
     subparagraph) for the State for the previous fiscal year 
     increased by the annual increase in the consumer price index 
     for all urban consumers (all items; U.S. city average) for 
     the fiscal year involved.
       ``(C) Availability of rollover funds.--The block grant 
     amount under this paragraph for a State for a fiscal year 
     shall remain available to the State for expenditures under 
     this subsection for the succeeding fiscal year but only if an 
     election is in effect under this subsection for the State in 
     such succeeding fiscal year.
       ``(4) Federal payment and state responsibility.--The 
     Secretary shall pay to each State with an election in effect 
     under this subsection for a fiscal year, from its block grant 
     amount under paragraph (3) available for such fiscal year, an 
     amount for each quarter of such fiscal year equal to the 
     enhanced FMAP described in the first sentence of section 
     2105(b) of the total amount expended under the State plan 
     under this subsection during such quarter, and the State is 
     responsible for the balance of funds to carry out such plan.
       ``(5) Block grant individual defined.--In this subsection, 
     the term `block grant individual' means, with respect to a 
     State for a 10-fiscal-year period, an individual who is not 
     disabled (as defined for purposes of the State plan) and who 
     is within an applicable block grant category for the State 
     and such period.
       ``(6) Applicable block grant category defined.--In this 
     subsection, the term `applicable block grant category' means 
     with respect to a State for a 10-fiscal-year period, either 
     of the following as specified by the State for such period in 
     its plan under paragraph (2)(A)(i):
       ``(A) 2 enrollee categories.--Both of the following 1903A 
     enrollee categories:
       ``(i) Children.--The 1903A enrollee category specified in 
     subparagraph (C) of subsection (e)(2).
       ``(ii) Other nonelderly, nondisabled, non-expansion 
     adults.--The 1903A enrollee category specified in 
     subparagraph (E) of such subsection.
       ``(B) Other nonelderly, nondisabled, non-expansion 
     adults.--Only the 1903A enrollee category specified in 
     subparagraph (E) of subsection (e)(2).
       ``(7) Block grant health care assistance.--In this 
     subsection, the term `block grant health care assistance' 
     means assistance for health-care-related items and medical 
     services for block grant individuals within the applicable 
     block grant category for the State and 10-fiscal-year period 
     involved who are low-income individuals (as defined by the 
     State).
       ``(8) Auditing.--As a condition of receiving funds under 
     this subsection, a State shall contract with an independent 
     entity to conduct audits of its expenditures made with 
     respect to activities funded under this subsection for each 
     fiscal year for which the State elects to apply this 
     subsection to ensure that such funds are used consistent with 
     this subsection and shall make such audits available to the 
     Secretary upon the request of the Secretary.''.

    Subtitle D--Patient Relief and Health Insurance Market Stability

     SEC. 131. REPEAL OF COST-SHARING SUBSIDY.

       (a) In General.--Section 1402 of the Patient Protection and 
     Affordable Care Act is repealed.
       (b) Effective Date.--The repeal made by subsection (a) 
     shall apply to cost-sharing reductions (and payments to 
     issuers for such reductions) for plan years beginning after 
     December 31, 2019.

     SEC. 132. PATIENT AND STATE STABILITY FUND.

       The Social Security Act (42 U.S.C. 301 et seq.) is amended 
     by adding at the end the following new title:

             ``TITLE XXII--PATIENT AND STATE STABILITY FUND

     ``SEC. 2201. ESTABLISHMENT OF PROGRAM.

       ``There is hereby established the `Patient and State 
     Stability Fund' to be administered by the Secretary of Health 
     and Human Services, acting through the Administrator of the 
     Centers for Medicare & Medicaid Services (in this section 
     referred to as the `Administrator'), to provide funding, in 
     accordance with this title, to the 50 States and the District 
     of Columbia (each referred to in this section as a `State') 
     during the period, subject to section 2204(c), beginning on 
     January 1, 2018, and ending on December 31, 2026, for the 
     purposes described in section 2202.

     ``SEC. 2202. USE OF FUNDS.

       ``(a) In General.--Subject to subsection (b), a State may 
     use the funds allocated to the State under this title for any 
     of the following purposes:
       ``(1) Helping, through the provision of financial 
     assistance, high-risk individuals who do not have access to 
     health insurance coverage offered through an employer enroll 
     in health insurance coverage in the individual market in the 
     State, as such market is defined by the State (whether 
     through the establishment of a new mechanism or maintenance 
     of an existing mechanism for such purpose).
       ``(2) Providing incentives to appropriate entities to enter 
     into arrangements with the State to help stabilize premiums 
     for health insurance coverage in the individual market, as 
     such markets are defined by the State.
       ``(3) Reducing the cost for providing health insurance 
     coverage in the individual market and small group market, as 
     such markets are defined by the State, to individuals who 
     have, or are projected to have, a high rate of utilization of 
     health services (as measured by cost) and to individuals who 
     have high costs of health insurance coverage due to the low 
     density population of the State in which they reside.
       ``(4) Promoting participation in the individual market and 
     small group market in the State and increasing health 
     insurance options available through such market.
       ``(5) Promoting access to preventive services; dental care 
     services (whether preventive or medically necessary); vision 
     care services (whether preventive or medically necessary); or 
     any combination of such services.
       ``(6) Maternity coverage and newborn care.
       ``(7) Prevention, treatment, or recovery support services 
     for individuals with mental or substance use disorders, 
     focused on either or both of the following:
       ``(A) Direct inpatient or outpatient clinical care for 
     treatment of addiction and mental illness.
       ``(B) Early identification and intervention for children 
     and young adults with serious mental illness.
       ``(8) Providing payments, directly or indirectly, to health 
     care providers for the provision of such health care services 
     as are specified by the Administrator.
       ``(9) Providing assistance to reduce out-of-pocket costs, 
     such as copayments, coinsurance, premiums, and deductibles, 
     of individuals enrolled in health insurance coverage in the 
     State.
       ``(b) Required Use of Increase in Allotment.--A State shall 
     use the additional allocation provided to the State from the 
     funds appropriated under the second sentence of section 
     2204(b) for each year only for the purposes described in 
     paragraphs (6) and (7) of subsection (a).

     ``SEC. 2203. STATE ELIGIBILITY AND APPROVAL; DEFAULT 
                   SAFEGUARD.

       ``(a) Encouraging State Options for Allocations.--
       ``(1) In general.--To be eligible for an allocation of 
     funds under this title for a year during the period described 
     in section 2201 for use for one or more purposes described in 
     section 2202, a State shall submit to the Administrator an 
     application at such time (but, in the case of allocations for 
     2018, not later than 45 days after the date of the enactment 
     of this title and, in the case of allocations for a 
     subsequent year, not later than March 31 of the previous 
     year) and in such form and manner as specified by the 
     Administrator and containing--
       ``(A) a description of how the funds will be used for such 
     purposes;
       ``(B) a certification that the State will make, from non-
     Federal funds, expenditures for such purposes in an amount 
     that is not less than the State percentage required for the 
     year under section 2204(e)(1); and
       ``(C) such other information as the Administrator may 
     require.
       ``(2) Automatic approval.--An application so submitted is 
     approved unless the Administrator notifies the State 
     submitting the application, not later than 60 days after the 
     date of the submission of such application, that the 
     application has been denied for not being in compliance with 
     any requirement of this title and of the reason for such 
     denial.
       ``(3) One-time application.--If an application of a State 
     is approved for a year, with respect to a purpose described 
     in section 2202, such application shall be treated as 
     approved, with respect to such purpose, for each subsequent 
     year through 2026.
       ``(4) Treatment as a state health care program.--Any 
     program receiving funds from an allocation for a State under 
     this title, including pursuant to subsection (b), shall be 
     considered to be a `State health care program' for purposes 
     of sections 1128, 1128A, and 1128B.
       ``(b) Default Federal Safeguard.--
       ``(1) In general.--
       ``(A) 2018.--For allocations made under this title for 
     2018, in the case of a State that does not submit an 
     application under subsection (a) by the 45-day submission 
     date applicable to such year under subsection (a)(1) and in 
     the case of a State that does submit such an application by 
     such date that is not approved, subject to section 2204(e), 
     the Administrator, in consultation with the State insurance 
     commissioner, shall use the allocation that would otherwise 
     be provided to the State under this title for such year, in 
     accordance with paragraph (2), for such State.
       ``(B) 2019 through 2026.--In the case of a State that does 
     not have in effect an approved application under this section 
     for 2019 or a subsequent year beginning during the period 
     described in section 2201, subject to

[[Page H2400]]

     section 2204(e), the Administrator, in consultation with the 
     State insurance commissioner, shall use the allocation that 
     would otherwise be provided to the State under this title for 
     such year, in accordance with paragraph (2), for such State.
       ``(2) Required use for market stabilization payments to 
     issuers.--Subject to section 2204(a), an allocation for a 
     State made pursuant to paragraph (1) for a year shall be used 
     to carry out the purpose described in section 2202(2) in such 
     State by providing payments to appropriate entities described 
     in such section with respect to claims that exceed $50,000 
     (or, with respect to allocations made under this title for 
     2020 or a subsequent year during the period specified in 
     section 2201, such dollar amount specified by the 
     Administrator), but do not exceed $350,000 (or, with respect 
     to allocations made under this title for 2020 or a subsequent 
     year during such period, such dollar amount specified by the 
     Administrator), in an amount equal to 75 percent (or, with 
     respect to allocations made under this title for 2020 or a 
     subsequent year during such period, such percentage specified 
     by the Administrator) of the amount of such claims.

     ``SEC. 2204. ALLOCATIONS.

       ``(a) Appropriation.--For the purpose of providing 
     allocations for States (including pursuant to section 
     2203(b)) under this title there is appropriated, out of any 
     money in the Treasury not otherwise appropriated--
       ``(1) for 2018, $15,000,000,000;
       ``(2) for 2019, $15,000,000,000;
       ``(3) for 2020, $10,000,000,000;
       ``(4) for 2021, $10,000,000,000;
       ``(5) for 2022, $10,000,000,000;
       ``(6) for 2023, $10,000,000,000;
       ``(7) for 2024, $10,000,000,000;
       ``(8) for 2025, $10,000,000,000; and
       ``(9) for 2026, $10,000,000,000.
     The amount otherwise appropriated under the previous sentence 
     for 2020 shall be increased by $15,000,000,000, to be used 
     and available under subsection (d) only for the purposes 
     described in paragraphs (6) and (7) of section 2202(a).
       ``(b) Allocations.--
       ``(1) Payment.--
       ``(A) In general.--From amounts appropriated under 
     subsection (a) for a year, the Administrator shall, with 
     respect to a State and not later than the date specified 
     under subparagraph (B) for such year, allocate, subject to 
     subsection (e), for such State (including pursuant to section 
     2203(b)) the amount determined for such State and year under 
     paragraph (2).
       ``(B) Specified date.--For purposes of subparagraph (A), 
     the date specified in this subparagraph is--
       ``(i) for 2018, the date that is 45 days after the date of 
     the enactment of this title; and
       ``(ii) for 2019 and subsequent years, January 1 of the 
     respective year.
       ``(2) Allocation amount determinations.--
       ``(A) For 2018 and 2019.--
       ``(i) In general.--For purposes of paragraph (1), the 
     amount determined under this paragraph for 2018 and 2019 for 
     a State is an amount equal to the sum of--

       ``(I) the relative incurred claims amount described in 
     clause (ii) for such State and year; and
       ``(II) the relative uninsured and issuer participation 
     amount described in clause (iv) for such State and year.

       ``(ii) Relative incurred claims amount.--For purposes of 
     clause (i), the relative incurred claims amount described in 
     this clause for a State for 2018 and 2019 is the product of--

       ``(I) 85 percent of the amount appropriated under 
     subsection (a) for the year; and
       ``(II) the relative State incurred claims proportion 
     described in clause (iii) for such State and year.

       ``(iii) Relative state incurred claims proportion.--The 
     relative State incurred claims proportion described in this 
     clause for a State and year is the amount equal to the ratio 
     of--

       ``(I) the adjusted incurred claims by the State, as 
     reported through the medical loss ratio annual reporting 
     under section 2718 of the Public Health Service Act for the 
     third previous year; to
       ``(II) the sum of such adjusted incurred claims for all 
     States, as so reported, for such third previous year.

       ``(iv) Relative uninsured and issuer participation 
     amount.--For purposes of clause (i), the relative uninsured 
     and issuer participation amount described in this clause for 
     a State for 2018 and 2019 is the product of--

       ``(I) 15 percent of the amount appropriated under 
     subsection (a) for the year; and
       ``(II) the relative State uninsured and issuer 
     participation proportion described in clause (v) for such 
     State and year.

       ``(v) Relative state uninsured and issuer participation 
     proportion.--The relative State uninsured and issuer 
     participation proportion described in this clause for a State 
     and year is--

       ``(I) in the case of a State not described in clause (vi) 
     for such year, 0; and
       ``(II) in the case of a State described in clause (vi) for 
     such year, the amount equal to the ratio of--

       ``(aa) the number of individuals residing in such State who 
     for the third preceding year were not enrolled in a health 
     plan or otherwise did not have health insurance coverage 
     (including through a Federal or State health program) and 
     whose income is below 100 percent of the poverty line 
     applicable to a family of the size involved; to
       ``(bb) the sum of the number of such individuals for all 
     States described in clause (vi) for the third preceding year.
       ``(vi) States described.--For purposes of clause (v), a 
     State is described in this clause, with respect to 2018 and 
     2019, if the State satisfies either of the following 
     criterion:

       ``(I) The ratio described in subclause (II) of clause (v) 
     that would be determined for such State by substituting 
     `2015' for each reference in such subclause to `the third 
     preceding year' and by substituting `all such States' for the 
     reference in item (bb) of such subclause to `all States 
     described in clause (vi)' is greater than the ratio described 
     in such subclause that would be determined for such State by 
     substituting `2013' for each reference in such subclause to 
     `the third preceding year' and by substituting `all such 
     States' for the reference in item (bb) of such subclause to 
     `all States described in clause (vi)'.
       ``(II) The State has fewer than three health insurance 
     issuers offering qualified health plans through the Exchange 
     for 2017.

       ``(B) For 2020 through 2026.--For purposes of paragraph 
     (1), the amount determined under this paragraph for a year 
     (beginning with 2020) during the period described in section 
     2201 for a State is an amount determined in accordance with 
     an allocation methodology specified by the Administrator 
     which--
       ``(i) takes into consideration the adjusted incurred claims 
     of such State, the number of residents of such State who for 
     the previous year were not enrolled in a health plan or 
     otherwise did not have health insurance coverage (including 
     through a Federal or State health program) and whose income 
     is below 100 percent of the poverty line applicable to a 
     family of the size involved, and the number of health 
     insurance issuers participating in the insurance market in 
     such State for such year;
       ``(ii) is established after consultation with health care 
     consumers, health insurance issuers, State insurance 
     commissioners, and other stakeholders and after taking into 
     consideration additional cost and risk factors that may 
     inhibit health care consumer and health insurance issuer 
     participation; and
       ``(iii) reflects the goals of improving the health 
     insurance risk pool, promoting a more competitive health 
     insurance market, and increasing choice for health care 
     consumers.
       ``(c) Annual Distribution of Previous Year's Remaining 
     Funds.-- In carrying out subsection (b), the Administrator 
     shall, with respect to a year (beginning with 2020 and ending 
     with 2027), not later than March 31 of such year--
       ``(1) determine the amount of funds, if any, from the 
     amounts appropriated under subsection (a) for the previous 
     year but not allocated for such previous year; and
       ``(2) if the Administrator determines that any funds were 
     not so allocated for such previous year, allocate such 
     remaining funds, in accordance with the allocation 
     methodology specified pursuant to subsection (b)(2)(B)--
       ``(A) to States that have submitted an application approved 
     under section 2203(a) for such previous year for any purpose 
     for which such an application was approved; and
       ``(B) for States for which allocations were made pursuant 
     to section 2203(b) for such previous year, to be used by the 
     Administrator for such States, to carry out the purpose 
     described in section 2202(2) in such States by providing 
     payments to appropriate entities described in such section 
     with respect to claims that exceed $1,000,000;
     with, respect to a year before 2027, any remaining funds 
     being made available for allocations to States for the 
     subsequent year.
       ``(d) Availability.--Amounts appropriated under subsection 
     (a) for a year and allocated to States in accordance with 
     this section shall remain available for expenditure through 
     December 31, 2027.
       ``(e) Conditions for and Limitations on Receipt of Funds.--
     The Secretary may not make an allocation under this title for 
     a State, with respect to a purpose described in section 
     2202--
       ``(1) in the case of an allocation that would be made to a 
     State pursuant to section 2203(a), if the State does not 
     agree that the State will make available non-Federal 
     contributions towards such purpose in an amount equal to--
       ``(A) for 2020, 7 percent of the amount allocated under 
     this subsection to such State for such year and purpose;
       ``(B) for 2021, 14 percent of the amount allocated under 
     this subsection to such State for such year and purpose;
       ``(C) for 2022, 21 percent of the amount allocated under 
     this subsection to such State for such year and purpose;
       ``(D) for 2023, 28 percent of the amount allocated under 
     this subsection to such State for such year and purpose;
       ``(E) for 2024, 35 percent of the amount allocated under 
     this subsection to such State for such year and purpose;
       ``(F) for 2025, 42 percent of the amount allocated under 
     this subsection to such State for such year and purpose; and
       ``(G) for 2026, 50 percent of the amount allocated under 
     this subsection to such State for such year and purpose;
       ``(2) in the case of an allocation that would be made for a 
     State pursuant to section 2203(b), if the State does not 
     agree that the State will make available non-Federal 
     contributions towards such purpose in an amount equal to--
       ``(A) for 2020, 10 percent of the amount allocated under 
     this subsection to such State for such year and purpose;

[[Page H2401]]

       ``(B) for 2021, 20 percent of the amount allocated under 
     this subsection to such State for such year and purpose; and
       ``(C) for 2022, 30 percent of the amount allocated under 
     this subsection to such State for such year and purpose;
       ``(D) for 2023, 40 percent of the amount allocated under 
     this subsection to such State for such year and purpose;
       ``(E) for 2024, 50 percent of the amount allocated under 
     this subsection to such State for such year and purpose;
       ``(F) for 2025, 50 percent of the amount allocated under 
     this subsection to such State for such year and purpose; and
       ``(G) for 2026, 50 percent of the amount allocated under 
     this subsection to such State for such year and purpose; or
       ``(3) if such an allocation for such purpose would not be 
     permitted under subsection (c)(7) of section 2105 if such 
     allocation were payment made under such section.''.

     SEC. 133. CONTINUOUS HEALTH INSURANCE COVERAGE INCENTIVE.

       Subpart I of part A of title XXVII of the Public Health 
     Service Act is amended--
       (1) in section 2701(a)(1)(B), by striking ``such rate'' and 
     inserting ``subject to section 2710A, such rate'';
       (2) by redesignating the second section 2709 as section 
     2710; and
       (3) by adding at the end the following new section:

     ``SEC. 2710A. ENCOURAGING CONTINUOUS HEALTH INSURANCE 
                   COVERAGE.

       ``(a) Penalty Applied.--
       ``(1) In general.--Notwithstanding section 2701, subject to 
     the succeeding provisions of this section, a health insurance 
     issuer offering health insurance coverage in the individual 
     market shall, in the case of an individual who is an 
     applicable policyholder of such coverage with respect to an 
     enforcement period applicable to enrollments for a plan year 
     beginning with plan year 2019 (or, in the case of enrollments 
     during a special enrollment period, beginning with plan year 
     2018), increase the monthly premium rate otherwise applicable 
     to such individual for such coverage during each month of 
     such period, by an amount determined under paragraph (2).
       ``(2) Amount of penalty.--The amount determined under this 
     paragraph for an applicable policyholder enrolling in health 
     insurance coverage described in paragraph (1) for a plan 
     year, with respect to each month during the enforcement 
     period applicable to enrollments for such plan year, is the 
     amount that is equal to 30 percent of the monthly premium 
     rate otherwise applicable to such applicable policyholder for 
     such coverage during such month.
       ``(b) Definitions.--For purposes of this section:
       ``(1) Applicable policyholder.--The term `applicable 
     policyholder' means, with respect to months of an enforcement 
     period and health insurance coverage, an individual who--
       ``(A) is a policyholder of such coverage for such months;
       ``(B) cannot demonstrate that (through presentation of 
     certifications described in section 2704(e) or in such other 
     manner as may be specified in regulations, such as a return 
     or statement made under section 6055(d) or 36B of the 
     Internal Revenue Code of 1986), during the look-back period 
     that is with respect to such enforcement period, there was 
     not a period of at least 63 continuous days during which the 
     individual did not have creditable coverage (as defined in 
     paragraph (1) of section 2704(c) and credited in accordance 
     with paragraphs (2) and (3) of such section); and
       ``(C) in the case of an individual who had been enrolled 
     under dependent coverage under a group health plan or health 
     insurance coverage by reason of section 2714 and such 
     dependent coverage of such individual ceased because of the 
     age of such individual, is not enrolling during the first 
     open enrollment period following the date on which such 
     coverage so ceased.
       ``(2) Look-back period.--The term `look-back period' means, 
     with respect to an enforcement period applicable to an 
     enrollment of an individual for a plan year beginning with 
     plan year 2019 (or, in the case of an enrollment of an 
     individual during a special enrollment period, beginning with 
     plan year 2018) in health insurance coverage described in 
     subsection (a)(1), the 12-month period ending on the date the 
     individual enrolls in such coverage for such plan year.
       ``(3) Enforcement period.--The term `enforcement period' 
     means--
       ``(A) with respect to enrollments during a special 
     enrollment period for plan year 2018, the period beginning 
     with the first month that is during such plan year and that 
     begins subsequent to such date of enrollment, and ending with 
     the last month of such plan year; and
       ``(B) with respect to enrollments for plan year 2019 or a 
     subsequent plan year, the 12-month period beginning on the 
     first day of the respective plan year.''.

     SEC. 134. INCREASING COVERAGE OPTIONS.

       Section 1302 of the Patient Protection and Affordable Care 
     Act (42 U.S.C. 18022) is amended--
       (1) in subsection (a)(3), by inserting ``and with respect 
     to a plan year before plan year 2020'' after ``subsection 
     (e)''; and
       (2) in subsection (d), by adding at the end the following:
       ``(5) Sunset.--The provisions of this subsection shall not 
     apply after December 31, 2019, and after such date any 
     reference to this subsection or level of coverage or plan 
     described in this subsection and any requirement under law 
     applying such a level of coverage or plan shall have no force 
     or effect (and such a requirement shall be applied as if this 
     section had been repealed).''.

     SEC. 135. CHANGE IN PERMISSIBLE AGE VARIATION IN HEALTH 
                   INSURANCE PREMIUM RATES.

       Section 2701(a)(1)(A)(iii) of the Public Health Service Act 
     (42 U.S.C. 300gg(a)(1)(A)(iii)), as inserted by section 
     1201(4) of the Patient Protection and Affordable Care Act, is 
     amended by inserting after ``(consistent with section 
     2707(c))'' the following: ``or, for plan years beginning on 
     or after January 1, 2018, as the Secretary may implement 
     through interim final regulation, 5 to 1 for adults 
     (consistent with section 2707(c)) or such other ratio for 
     adults (consistent with section 2707(c)) as the State 
     involved may provide''.

     SEC. 136. ESSENTIAL HEALTH BENEFITS DEFINED BY THE STATES.

       Section 1302 of the Patient Protection and Affordable Care 
     Act (42 U.S.C. 18022) is amended--
       (1) in subsection (a)(1), by striking ``by the Secretary''; 
     and
       (2) in subsection (b)--
       (A) in paragraph (1), by striking ``paragraph (2)'' and 
     inserting ``paragraphs (2) and (6)''; and
       (B) by adding at the end the following new paragraph:
       ``(6) Essential health benefits for plan and taxable years 
     beginning on or after january 1, 2018.--For plan years and 
     taxable years beginning on or after January 1, 2018, each 
     State shall define the essential health benefits with respect 
     to health plans offered in such State, for the purposes of 
     section 36B of the Internal Revenue Code of 1986.''.

                   Subtitle E--Implementation Funding

     SEC. 141. AMERICAN HEALTH CARE IMPLEMENTATION FUND.

       (a) In General.--There is hereby established an American 
     Health Care Implementation Fund (referred to in this section 
     as the ``Fund'') within the Department of Health and Human 
     Services to carry out sections 121, 132, 202, and 214 
     (including the amendments made by such sections).
       (b) Funding.--There is appropriated to the Fund, out of any 
     funds in the Treasury not otherwise appropriated, 
     $1,000,000,000 for Federal administrative expenses to carry 
     out the sections described in subsection (a) (including the 
     amendments made by such sections).

                 TITLE II--COMMITTEE ON WAYS AND MEANS

      Subtitle A--Repeal and Replace of Health-Related Tax Policy

     SEC. 201. RECAPTURE EXCESS ADVANCE PAYMENTS OF PREMIUM TAX 
                   CREDITS.

       Subparagraph (B) of section 36B(f)(2) of the Internal 
     Revenue Code of 1986 is amended by adding at the end the 
     following new clause:
       ``(iii) Nonapplicability of limitation.--This subparagraph 
     shall not apply to taxable years beginning after December 31, 
     2017, and before January 1, 2020.''.

     SEC. 202. ADDITIONAL MODIFICATIONS TO PREMIUM TAX CREDIT.

       (a) Modification of Definition of Qualified Health Plan.--
       (1) In general.--Section 36B(c)(3)(A) of the Internal 
     Revenue Code of 1986 is amended--
       (A) by inserting ``(determined without regard to 
     subparagraphs (A), (C)(ii), and (C)(iv) of paragraph (1) 
     thereof and without regard to whether the plan is offered on 
     an Exchange)'' after ``1301(a) of the Patient Protection and 
     Affordable Care Act'', and
       (B) by striking ``shall not include'' and all that follows 
     and inserting ``shall not include any health plan that--
       ``(i) is a grandfathered health plan or a grandmothered 
     health plan, or
       ``(ii) includes coverage for abortions (other than any 
     abortion necessary to save the life of the mother or any 
     abortion with respect to a pregnancy that is the result of an 
     act of rape or incest).''.
       (2) Definition of grandmothered health plan.--Section 
     36B(c)(3) of such Code is amended by adding at the end the 
     following new subparagraph:
       ``(C) Grandmothered health plan.--
       ``(i) In general.--The term `grandmothered health plan' 
     means health insurance coverage which is offered in the 
     individual health insurance market as of October 1, 2013, and 
     is permitted to be offered in such market after January 1, 
     2014, as a result of CCIIO guidance.
       ``(ii) CCIIO guidance defined.--The term `CCIIO guidance' 
     means the letter issued by the Centers for Medicare & 
     Medicaid Services on November 14, 2013, to the State 
     Insurance Commissioners outlining a transitional policy for 
     non-grandfathered coverage in the individual health insurance 
     market, as subsequently extended and modified (including by a 
     communication entitled `Insurance Standards Bulletin Series--
     INFORMATION--Extension of Transitional Policy through 
     Calendar Year 2017' issued on February 29, 2016, by the 
     Director of the Center for Consumer Information & Insurance 
     Oversight of such Centers).
       ``(iii) Individual health insurance market.--The term 
     `individual health insurance market' means the market for 
     health insurance coverage (as defined in section 9832(b)) 
     offered to individuals other than in connection with a group 
     health plan (within the meaning of section 5000(b)(1)).''.
       (3) Conforming amendment related to abortion coverage.--
     Section 36B(c)(3) of

[[Page H2402]]

     such Code, as amended by paragraph (2), is amended by adding 
     at the end the following new subparagraph:
       ``(D) Certain rules related to abortion.--
       ``(i) Option to purchase separate coverage or plan.--
     Nothing in subparagraph (A) shall be construed as prohibiting 
     any individual from purchasing separate coverage for 
     abortions described in such subparagraph, or a health plan 
     that includes such abortions, so long as no credit is allowed 
     under this section with respect to the premiums for such 
     coverage or plan.
       ``(ii) Option to offer coverage or plan.--Nothing in 
     subparagraph (A) shall restrict any health insurance issuer 
     offering a health plan from offering separate coverage for 
     abortions described in such subparagraph, or a plan that 
     includes such abortions, so long as premiums for such 
     separate coverage or plan are not paid for with any amount 
     attributable to the credit allowed under this section (or the 
     amount of any advance payment of the credit under section 
     1412 of the Patient Protection and Affordable Care Act).
       ``(iii) Other treatments.--The treatment of any infection, 
     injury, disease, or disorder that has been caused by or 
     exacerbated by the performance of an abortion shall not be 
     treated as an abortion for purposes of subparagraph (A).''.
       (4) Conforming amendments related to off-exchange 
     coverage.--
       (A) Advance payment not applicable.--Section 1412 of the 
     Patient Protection and Affordable Care Act is amended by 
     adding at the end the following new subsection:
       ``(f) Exclusion of Off-Exchange Coverage.--Advance payments 
     under this section, and advance determinations under section 
     1411, with respect to any credit allowed under section 36B 
     shall not be made with respect to any health plan which is 
     not enrolled in through an Exchange.''.
       (B) Reporting.--Section 6055(b) of the Internal Revenue 
     Code of 1986 is amended by adding at the end the following 
     new paragraph:
       ``(3) Information relating to off-exchange premium credit 
     eligible coverage.--If minimum essential coverage provided to 
     an individual under subsection (a) consists of a qualified 
     health plan (as defined in section 36B(c)(3)) which is not 
     enrolled in through an Exchange established under title I of 
     the Patient Protection and Affordable Care Act, a return 
     described in this subsection shall include--
       ``(A) a statement that such plan is a qualified health plan 
     (as defined in section 36B(c)(3)),
       ``(B) the premiums paid with respect to such coverage,
       ``(C) the months during which such coverage is provided to 
     the individual,
       ``(D) the adjusted monthly premium for the applicable 
     second lowest cost silver plan (as defined in section 
     36B(b)(3)) for each such month with respect to such 
     individual, and
       ``(E) such other information as the Secretary may 
     prescribe.''.
       (C) Other conforming amendments.--
       (i) Section 36B(b)(2)(A) of such Code is amended by 
     striking ``and which were enrolled'' and all that follows and 
     inserting ``, or''.
       (ii) Section 36B(b)(3)(B)(i) of such Code is amended by 
     striking ``the same Exchange'' and all that follows and 
     inserting ``the Exchange through which such taxpayer is 
     permitted to obtain coverage, and''.
       (iii) Section 36B(c)(2)(A)(i) of such Code is amended by 
     striking ``that was enrolled in through an Exchange 
     established by the State under section 1311 of the Patient 
     Protection and Affordable Care Act''.
       (b) Modification of Applicable Percentage.--Section 
     36B(b)(3)(A) of such Code is amended to read as follows:
       ``(A) Applicable percentage.--
       ``(i) In general.--The applicable percentage for any 
     taxable year shall be the percentage such that the applicable 
     percentage for any taxpayer whose household income is within 
     an income tier specified in the following table shall 
     increase, on a sliding scale in a linear manner, from the 
     initial percentage to the final percentage specified in such 
     table for such income tier with respect to a taxpayer of the 
     age involved:


------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
  ``In the case of              Up to Age 29                         Age 30-39                          Age 40-49                         Age 50-59                        Over Age 59
  household income  ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------
  (expressed as a
   percent of the
   poverty line)
     within the          Initial %          Final %          Initial %         Final %         Initial %         Final %         Initial %         Final %         Initial %         Final %
  following income
       tier:
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Up to 133%           2...............  2...............  2...............  2..............  2..............  2..............  2..............  2..............  2..............  2
133%-150%            3...............  4...............  3...............  4..............  3..............  4..............  3..............  4..............  3..............  4
150%-200%            4...............  4.3.............  4...............  5.3............  4..............  6.3............  4..............  7.3............  4..............  8.3
200%-250%            4.3.............  4.3.............  5.3.............  5.9............  6.3............  8.05...........  7.3............  9..............  8.3............  10
250%-300%            4.3.............  4.3.............  5.9.............  5.9............  8.05...........  8.35...........  9..............  10.5...........  10.............  11.5
300%-400%            4.3.............  4.3.............  5.9.............  5.9............  8.35...........  8.35...........  10.5...........  10.5...........  11.5...........  11.5
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

       ``(ii) Age determinations.--

       ``(I) In general.--For purposes of clause (i), the age of 
     the taxpayer taken into account under clause (i) with respect 
     to any taxable year is the age attained by such taxpayer 
     before the close of such taxable year.
       ``(II) Joint returns.--In the case of a joint return, the 
     age of the older spouse shall be taken into account under 
     clause (i).

       ``(iii) Indexing.--In the case of any taxable year 
     beginning in calendar year 2019, the initial and final 
     percentages contained in clause (i) shall be adjusted to 
     reflect--

       ``(I) the excess (if any) of the rate of premium growth for 
     the period beginning with calendar year 2013 and ending with 
     calendar year 2018, over the rate of income growth for such 
     period, and
       ``(II) in addition to any adjustment under subclause (I), 
     the excess (if any) of the rate of premium growth for 
     calendar year 2018, over the rate of growth in the consumer 
     price index for calendar year 2018.

       ``(iv) Failsafe.--Clause (iii)(II) shall apply only if the 
     aggregate amount of premium tax credits under this section 
     and cost-sharing reductions under section 1402 of the Patient 
     Protection and Affordable Care Act for calendar year 2018 
     exceeds an amount equal to 0.504 percent of the gross 
     domestic product for such calendar year.''.
       (c) Effective Date.--
       (1) In general.--Except as otherwise provided in this 
     subsection, the amendments made by this section shall apply 
     to taxable years beginning after December 31, 2017.
       (2) Advance payment not applicable to off-exchange 
     coverage.--The amendment made by subsection (a)(4)(A) shall 
     take effect on January 1, 2018.
       (3) Reporting.--The amendment made by subsection (a)(4)(B) 
     shall apply to coverage provided for months beginning after 
     December 31, 2017.
       (4) Modification of applicable percentage.--The amendment 
     made by subsection (b) shall apply to taxable years beginning 
     after December 31, 2018.

     SEC. 203. SMALL BUSINESS TAX CREDIT.

       (a) In General.--Section 45R of the Internal Revenue Code 
     of 1986 is amended by adding at the end the following new 
     subsection:
       ``(j) Shall Not Apply.--This section shall not apply with 
     respect to amounts paid or incurred in taxable years 
     beginning after December 31, 2019.''.
       (b) Disallowance of Small Employer Health Insurance Expense 
     Credit for Plan Which Includes Coverage for Abortion.--
     Subsection (h) of section 45R of the Internal Revenue Code of 
     1986 is amended--
       (1) by striking ``Any term'' and inserting the following:
       ``(1) In general.--Any term''; and
       (2) by adding at the end the following new paragraph:
       ``(2) Exclusion of health plans including coverage for 
     abortion.--
       ``(A) In general.--The term `qualified health plan' does 
     not include any health plan that includes coverage for 
     abortions (other than any abortion necessary to save the life 
     of the mother or any abortion with respect to a pregnancy 
     that is the result of an act of rape or incest) .
       ``(B) Certain rules related to abortion.--
       ``(i) Option to purchase separate coverage or plan.--
     Nothing in subparagraph (A) shall be construed as prohibiting 
     any employer from purchasing for its employees separate 
     coverage for abortions described in such subparagraph, or a 
     health plan that includes such abortions, so long as no 
     credit is allowed under this section with respect to the 
     employer contributions for such coverage or plan.
       ``(ii) Option to offer coverage or plan.--Nothing in 
     subparagraph (A) shall restrict any health insurance issuer 
     offering a health plan from offering separate coverage for 
     abortions described in such subparagraph, or a plan that 
     includes such abortions, so long as such separate coverage or 
     plan is not paid for with any employer contribution eligible 
     for the credit allowed under this section.
       ``(iii) Other treatments.--The treatment of any infection, 
     injury, disease, or disorder that has been caused by or 
     exacerbated by the performance of an abortion shall not be 
     treated as an abortion for purposes of subparagraph (A).''.
       (c) Effective Dates.--
       (1) In general.--The amendment made by subsection (a) shall 
     apply to taxable years beginning after December 31, 2019.
       (2) Disallowance of small employer health insurance expense 
     credit for plan which includes coverage for abortion.--The 
     amendments made by subsection (b)

[[Page H2403]]

     shall apply to taxable years beginning after December 31, 
     2017.

     SEC. 204. INDIVIDUAL MANDATE.

       (a) In General.--Section 5000A(c) of the Internal Revenue 
     Code of 1986 is amended--
       (1) in paragraph (2)(B)(iii), by striking ``2.5 percent'' 
     and inserting ``Zero percent'', and
       (2) in paragraph (3)--
       (A) by striking ``$695'' in subparagraph (A) and inserting 
     ``$0'', and
       (B) by striking subparagraph (D).
       (b) Effective Date.--The amendments made by this section 
     shall apply to months beginning after December 31, 2015.

     SEC. 205. EMPLOYER MANDATE.

       (a) In General.--
       (1) Paragraph (1) of section 4980H(c) of the Internal 
     Revenue Code of 1986 is amended by inserting ``($0 in the 
     case of months beginning after December 31, 2015)'' after 
     ``$2,000''.
       (2) Paragraph (1) of section 4980H(b) of the Internal 
     Revenue Code of 1986 is amended by inserting ``($0 in the 
     case of months beginning after December 31, 2015)'' after 
     ``$3,000''.
       (b) Effective Date.--The amendments made by this section 
     shall apply to months beginning after December 31, 2015.

     SEC. 206. REPEAL OF THE TAX ON EMPLOYEE HEALTH INSURANCE 
                   PREMIUMS AND HEALTH PLAN BENEFITS.

       Section 4980I of the Internal Revenue Code of 1986 is 
     amended by adding at the end the following new subsection:
       ``(h) Shall Not Apply.--No tax shall be imposed under this 
     section with respect to any taxable period beginning after 
     December 31, 2019, and before January 1, 2026.''.

     SEC. 207. REPEAL OF TAX ON OVER-THE-COUNTER MEDICATIONS.

       (a) HSAs.--Subparagraph (A) of section 223(d)(2) of the 
     Internal Revenue Code of 1986 is amended by striking ``Such 
     term'' and all that follows through the period.
       (b) Archer MSAs.--Subparagraph (A) of section 220(d)(2) of 
     the Internal Revenue Code of 1986 is amended by striking 
     ``Such term'' and all that follows through the period.
       (c) Health Flexible Spending Arrangements and Health 
     Reimbursement Arrangements.--Section 106 of the Internal 
     Revenue Code of 1986 is amended by striking subsection (f) 
     and by redesignating subsection (g) as subsection (f).
       (d) Effective Dates.--
       (1) Distributions from savings accounts.--The amendments 
     made by subsections (a) and (b) shall apply to amounts paid 
     with respect to taxable years beginning after December 31, 
     2016.
       (2) Reimbursements.--The amendment made by subsection (c) 
     shall apply to expenses incurred with respect to taxable 
     years beginning after December 31, 2016.

     SEC. 208. REPEAL OF INCREASE OF TAX ON HEALTH SAVINGS 
                   ACCOUNTS.

       (a) HSAs.--Section 223(f)(4)(A) of the Internal Revenue 
     Code of 1986 is amended by striking ``20 percent'' and 
     inserting ``10 percent''.
       (b) Archer MSAs.--Section 220(f)(4)(A) of the Internal 
     Revenue Code of 1986 is amended by striking ``20 percent'' 
     and inserting ``15 percent''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to distributions made after December 31, 2016.

     SEC. 209. REPEAL OF LIMITATIONS ON CONTRIBUTIONS TO FLEXIBLE 
                   SPENDING ACCOUNTS.

       (a) In General.--Section 125 of the Internal Revenue Code 
     of 1986 is amended by striking subsection (i).
       (b) Effective Date.--The amendment made by this section 
     shall apply to taxable years beginning after December 31, 
     2016.

     SEC. 210. REPEAL OF MEDICAL DEVICE EXCISE TAX.

       Section 4191 of the Internal Revenue Code of 1986 is 
     amended by adding at the end the following new subsection:
       ``(d) Applicability.--The tax imposed under subsection (a) 
     shall not apply to sales after December 31, 2016.''.

     SEC. 211. REPEAL OF ELIMINATION OF DEDUCTION FOR EXPENSES 
                   ALLOCABLE TO MEDICARE PART D SUBSIDY.

       (a) In General.--Section 139A of the Internal Revenue Code 
     of 1986 is amended by adding at the end the following new 
     sentence: ``This section shall not be taken into account for 
     purposes of determining whether any deduction is allowable 
     with respect to any cost taken into account in determining 
     such payment.''.
       (b) Effective Date.--The amendment made by this section 
     shall apply to taxable years beginning after December 31, 
     2016.

     SEC. 212. REDUCTION OF INCOME THRESHOLD FOR DETERMINING 
                   MEDICAL CARE DEDUCTION.

       (a) In General.--Subsection (a) of section 213 of the 
     Internal Revenue Code of 1986 is amended by striking ``10 
     percent'' and inserting ``5.8 percent''.
       (b) Effective Date.--The amendment made by this section 
     shall apply to taxable years beginning after December 31, 
     2016.

     SEC. 213. REPEAL OF MEDICARE TAX INCREASE.

       (a) In General.--Subsection (b) of section 3101 of the 
     Internal Revenue Code of 1986 is amended to read as follows:
       ``(b) Hospital Insurance.--In addition to the tax imposed 
     by the preceding subsection, there is hereby imposed on the 
     income of every individual a tax equal to 1.45 percent of the 
     wages (as defined in section 3121(a)) received by such 
     individual with respect to employment (as defined in section 
     3121(b)).''.
       (b) SECA.--Subsection (b) of section 1401 of the Internal 
     Revenue Code of 1986 is amended to read as follows:
       ``(b) Hospital Insurance.--In addition to the tax imposed 
     by the preceding subsection, there shall be imposed for each 
     taxable year, on the self-employment income of every 
     individual, a tax equal to 2.9 percent of the amount of the 
     self-employment income for such taxable year.''.
       (c) Effective Date.--The amendments made by this section 
     shall apply with respect to remuneration received after, and 
     taxable years beginning after, December 31, 2022.

     SEC. 214. REFUNDABLE TAX CREDIT FOR HEALTH INSURANCE 
                   COVERAGE.

       (a) In General.--Section 36B of the Internal Revenue Code 
     of 1986 is amended to read as follows:

     ``SEC. 36B. REFUNDABLE CREDIT FOR COVERAGE UNDER A QUALIFIED 
                   HEALTH PLAN.

       ``(a) Allowance of Premium Tax Credit.--In the case of an 
     individual, there shall be allowed as a credit against the 
     tax imposed by this subtitle for the taxable year the sum of 
     the monthly credit amounts with respect to such taxpayer for 
     calendar months during such taxable year which are eligible 
     coverage months appropriately taken into account under 
     subsection (b)(2) with respect to the taxpayer or any 
     qualifying family member of the taxpayer.
       ``(b) Monthly Credit Amounts.--
       ``(1) In general.--The monthly credit amount with respect 
     to any taxpayer for any calendar month is the lesser of--
       ``(A) the sum of the monthly limitation amounts determined 
     under subsection (c) with respect to the taxpayer and the 
     taxpayer's qualifying family members for such month, or
       ``(B) the amount paid for a qualified health plan for the 
     taxpayer and the taxpayer's qualifying family members for 
     such month.
       ``(2) Eligible coverage month requirement.--No amount shall 
     be taken into account under subparagraph (A) or (B) of 
     paragraph (1) with respect to any individual for any month 
     unless such month is an eligible coverage month with respect 
     to such individual.
       ``(c) Monthly Limitation Amounts.--
       ``(1) In general.--The monthly limitation amount with 
     respect to any individual for any eligible coverage month 
     during any taxable year is \1/12\ of--
       ``(A) $2,000 in the case of an individual who has not 
     attained age 30 as of the beginning of such taxable year,
       ``(B) $2,500 in the case of an individual who has attained 
     age 30 but who has not attained age 40 as of such time,
       ``(C) $3,000 in the case of an individual who has attained 
     age 40 but who has not attained age 50 as of such time,
       ``(D) $3,500 in the case of an individual who has attained 
     age 50 but who has not attained age 60 as of such time, and
       ``(E) $4,000 in the case of an individual who has attained 
     age 60 as of such time.
       ``(2) Limitation based on modified adjusted gross income.--
     The credit allowed under subsection (a) with respect to any 
     taxpayer for any taxable year shall be reduced (but not below 
     zero) by 10 percent of the excess (if any) of--
       ``(A) the taxpayer's modified adjusted gross income (as 
     defined in section 36B(d)(2)(B), as in effect for taxable 
     years beginning before January 1, 2020) for such taxable 
     year, over
       ``(B) $75,000 (twice such amount in the case of a joint 
     return).
       ``(3) Other limitations.--
       ``(A) Aggregate dollar limitation.--The sum of the monthly 
     limitation amounts taken into account under this section with 
     respect to any taxpayer for any taxable year shall not exceed 
     $14,000.
       ``(B) Maximum number of individuals taken into account.--
     With respect to any taxpayer for any month, monthly 
     limitation amounts shall be taken into account under this 
     section only with respect to the 5 oldest individuals with 
     respect to whom monthly limitation amounts could (without 
     regard to this subparagraph) otherwise be so taken into 
     account.
       ``(d) Eligible Coverage Month.--For purposes of this 
     section, the term `eligible coverage month' means, with 
     respect to any individual, any month if, as of the first day 
     of such month, the individual meets the following 
     requirements:
       ``(1) The individual is covered by a health insurance 
     coverage which is certified by the State in which such 
     insurance is offered as coverage that meets the requirements 
     for qualified health plans under subsection (f).
       ``(2) The individual is not eligible for--
       ``(A) coverage under a group health plan (within the 
     meaning of section 5000(b)(1)) other than coverage under a 
     plan substantially all of the coverage of which is of 
     excepted benefits described in section 9832(c), or
       ``(B) coverage described in section 5000A(f)(1)(A).
       ``(3) The individual is either--
       ``(A) a citizen or national of the United States, or
       ``(B) a qualified alien (within the meaning of section 431 
     of the Personal Responsibility and Work Opportunity 
     Reconciliation Act of 1996 (8 U.S.C. 1641)).
       ``(4) The individual is not incarcerated, other than 
     incarceration pending the disposition of charges.
       ``(e) Qualifying Family Member.--For purposes of this 
     section, the term `qualifying family member' means--
       ``(1) in the case of a joint return, the taxpayer's spouse,

[[Page H2404]]

       ``(2) any dependent of the taxpayer, and
       ``(3) with respect to any eligible coverage month, any 
     child (as defined in section 152(f)(1)) of the taxpayer who 
     as of the end of the taxable year has not attained age 27 if 
     such child is covered for such month under a qualified health 
     plan which also covers the taxpayer (in the case of a joint 
     return, either spouse).
       ``(f) Qualified Health Plan.--For purposes of this section, 
     the term `qualified health plan' means any health insurance 
     coverage (as defined in section 9832(b)) if--
       ``(1) such coverage is offered in the individual health 
     insurance market within a State (within the meaning of 
     section 5000A(f)(1)(C)),
       ``(2) substantially all of such coverage is not of excepted 
     benefits described in section 9832(c),
       ``(3) such coverage does not consist of short-term limited 
     duration insurance (within the meaning of section 2791(b)(5) 
     of the Public Health Service Act),
       ``(4) such coverage is not a grandfathered health plan (as 
     defined in section 1251 of the Patient Protection and 
     Affordable Care Act) or a grandmothered health plan (as 
     defined in section 36B(c)(3)(C) as in effect for taxable 
     years beginning before January 1, 2020), and
       ``(5) such coverage does not include coverage for abortions 
     (other than any abortion necessary to save the life of the 
     mother or any abortion with respect to a pregnancy that is 
     the result of an act of rape or incest).
       ``(g) Special Rules.--
       ``(1) Married couples must file joint return.--
       ``(A) In general.--Except as provided in subparagraph (B), 
     if the taxpayer is married (within the meaning of section 
     7703) at the close of the taxable year, no credit shall be 
     allowed under this section to such taxpayer unless such 
     taxpayer and the taxpayer's spouse file a joint return for 
     such taxable year.
       ``(B) Exception for certain taxpayers.--Subparagraph (A) 
     shall not apply to any married taxpayer who--
       ``(i) is living apart from the taxpayer's spouse at the 
     time the taxpayer files the tax return,
       ``(ii) is unable to file a joint return because such 
     taxpayer is a victim of domestic abuse or spousal 
     abandonment,
       ``(iii) certifies on the tax return that such taxpayer 
     meets the requirements of clauses (i) and (ii), and
       ``(iv) has not met the requirements of clauses (i), (ii), 
     and (iii) for each of the 3 preceding taxable years.
       ``(2) Denial of credit to dependents.--
       ``(A) In general.--No credit shall be allowed under this 
     section to any individual who is a dependent with respect to 
     another taxpayer for a taxable year beginning in the calendar 
     year in which such individual's taxable year begins.
       ``(B) Coordination with rule for older children.--In the 
     case of any individual who is a qualifying family member 
     described in subsection (e)(3) with respect to another 
     taxpayer for any month, in determining the amount of any 
     credit allowable to such individual under this section for 
     any taxable year of such individual which includes such 
     month, the monthly limitation amount with respect to such 
     individual for such month shall be zero and no amount paid 
     for any qualified health plan with respect to such individual 
     for such month shall be taken into account.
       ``(3) Coordination with medical expense deduction.--Amounts 
     described in subsection (b)(1)(B) with respect to any month 
     shall not be taken into account in determining the deduction 
     allowed under section 213 except to the extent that such 
     amounts exceed the amount described in subsection (b)(1)(A) 
     with respect to such month.
       ``(4) Coordination with advance payments of credit.--With 
     respect to any taxable year--
       ``(A) the amount which would (but for this subsection) be 
     allowed as a credit to the taxpayer under subsection (a) 
     shall be reduced (but not below zero) by the aggregate amount 
     paid on behalf of such taxpayer under section 1412 of the 
     Patient Protection and Affordable Care Act for months 
     beginning in such taxable year, and
       ``(B) the tax imposed by section 1 for such taxable year 
     shall be increased by the excess (if any) of--
       ``(i) the aggregate amount paid on behalf of such taxpayer 
     under such section 1412 for months beginning in such taxable 
     year, over
       ``(ii) the amount which would (but for this subsection) be 
     allowed as a credit to the taxpayer under subsection (a).
       ``(5) Special rules for qualified small employer health 
     reimbursement arrangements.--
       ``(A) In general.--If the taxpayer or any qualifying family 
     member of the taxpayer is provided a qualified small employer 
     health reimbursement arrangement for an eligible coverage 
     month, the sum determined under subsection (b)(1)(A) with 
     respect to the taxpayer shall be reduced (but not below zero) 
     by \1/12\ of the permitted benefit (as defined in section 
     9831(d)(3)(C)) under such arrangement for each such month 
     such arrangement is provided to such taxpayer.
       ``(B) Qualified small employer health reimbursement 
     arrangement.--For purposes of this paragraph, the term 
     `qualified small employer health reimbursement arrangement' 
     has the meaning given such term by section 9831(d)(2).
       ``(C) Coverage for less than entire year.--In the case of 
     an employee who is provided a qualified small employer health 
     reimbursement arrangement for less than an entire year, 
     subparagraph (A) shall be applied by substituting `the number 
     of months during the year for which such arrangement was 
     provided' for `12'.
       ``(6) Certain rules related to nonqualified health plans.--
     The rules of section 36B(c)(3)(D), as in effect for taxable 
     years beginning before January 1, 2020, shall apply with 
     respect to subsection (f)(5).
       ``(7) Inflation adjustment.--
       ``(A) In general.--In the case of any taxable year 
     beginning in a calendar year after 2020, each dollar amount 
     in subsection (c)(1), the $75,000 amount in subsection 
     (c)(2)(B), and the dollar amount in subsection (c)(3)(A), 
     shall be increased by an amount equal to--
       ``(i) such dollar amount, multiplied by
       ``(ii) the cost-of-living adjustment determined under 
     section 1(f)(3) for the calendar year in which the taxable 
     year begins, determined--

       ``(I) by substituting `calendar year 2019' for `calendar 
     year 1992' in subparagraph (B) thereof, and
       ``(II) by substituting for the CPI referred to section 
     1(f)(3)(A) the amount that such CPI would have been if the 
     annual percentage increase in CPI with respect to each year 
     after 2019 had been one percentage point greater.

       ``(B) Terms related to cpi.--
       ``(i) Annual percentage increase.--For purposes of 
     subparagraph (A)(ii)(II), the term `annual percentage 
     increase' means the percentage (if any) by which CPI for any 
     year exceeds CPI for the prior year.
       ``(ii) Other terms.--Terms used in this paragraph which are 
     also used in section 1(f)(3) shall have the same meanings as 
     when used in such section.
       ``(C) Rounding.--Any increase determined under subparagraph 
     (A) shall be rounded to the nearest multiple of $50.
       ``(8) Rules related to state certification of qualified 
     health plans.--A certification shall not be taken into 
     account under subsection (d)(1) unless such certification is 
     made available to the public and meets such other 
     requirements as the Secretary may provide.
       ``(9) Regulations.--The Secretary may prescribe such 
     regulations and other guidance as may be necessary or 
     appropriate to carry out this section and section 1412 of the 
     Patient Protection and Affordable Care Act.''.
       (b) Advance Payment of Credit.--Section 1412 of the Patient 
     Protection and Affordable Care Act is amended by adding at 
     the end the following new subsection:
       ``(f) Application to Certain Plans.--The Secretary and the 
     Secretary of the Treasury shall prescribe such regulations as 
     each respective Secretary may deem necessary in order to 
     establish and operate the advance payment program established 
     under this section for individuals covered under qualified 
     health plans (whether enrolled in through an Exchange or 
     otherwise) in such a manner that protects taxpayer 
     information (including names, taxpayer identification 
     numbers, and other confidential information), provides robust 
     verification of all information necessary to establish 
     eligibility of taxpayer for advance payments under this 
     section, ensures proper and timely payments to appropriate 
     health providers, and protects program integrity to the 
     maximum extent feasible.''.
       (c) Increased Penalty on Erroneous Claims of Credit.--
     Section 6676(a) of the Internal Revenue Code of 1986 is 
     amended by inserting ``(25 percent in the case of a claim for 
     refund or credit relating to the health insurance coverage 
     credit under section 36B)''.
       (d) Reporting by Employers.--Section 6051(a) of such Code 
     is amended by striking ``and'' at the end of paragraph (14), 
     by striking the period at the end of paragraph (15) and 
     inserting ``, and'', and by inserting after paragraph (15) 
     the following new paragraph:
       ``(16) each month with respect to which the employee is 
     eligible for coverage described in section 36B(d)(2) in 
     connection with employment with the employer.''.
       (e) Coordination With Other Tax Benefits.--
       (1) Credit for health insurance costs of eligible 
     individuals.--Section 35(g) of such Code is amended by adding 
     at the end the following new paragraph:
       ``(14) Coordination with health insurance coverage 
     credit.--
       ``(A) In general.--An eligible coverage month to which the 
     election under paragraph (11) applies shall not be treated as 
     an eligible coverage month (as defined in section 36B(d)) for 
     purposes of section 36B with respect to the taxpayer or any 
     of the taxpayer's qualifying family members (as defined in 
     section 36B(e)).
       ``(B) Coordination with advance payments of health 
     insurance coverage credit.--In the case of a taxpayer who 
     makes the election under paragraph (11) with respect to any 
     eligible coverage month in a taxable year or on behalf of 
     whom any advance payment is made under section 7527 with 
     respect to any month in such taxable year--
       ``(i) the tax imposed by this chapter for the taxable year 
     shall be increased by the excess, if any, of--

       ``(I) the sum of any advance payments made on behalf of the 
     taxpayer under section 7527 and section 1412 of the Patient 
     Protection and Affordable Care Act, over
       ``(II) the sum of the credits allowed under this section 
     (determined without regard to

[[Page H2405]]

     paragraph (1)) and section 36B (determined without regard to 
     subsection (g)(4)(A) thereof) for such taxable year, and

       ``(ii) section 36B(g)(4)(B) shall not apply with respect to 
     such taxpayer for such taxable year.''.
       (2) Trade or business deduction.--Section 162(l) of such 
     Code is amended by adding at the end the following new 
     paragraph:
       ``(6) Coordination with health insurance coverage credit.--
     The deduction otherwise allowable to a taxpayer under 
     paragraph (1) for any taxable year shall be reduced (but not 
     below zero) by the amount of the credit allowable to such 
     taxpayer under section 36B (determined without regard to 
     subsection (g)(4)(A) thereof) for such taxable year.''.
       (f) Effective Date.--The amendments made by this section 
     shall apply to months beginning after December 31, 2019, in 
     taxable years ending after such date.

     SEC. 215. MAXIMUM CONTRIBUTION LIMIT TO HEALTH SAVINGS 
                   ACCOUNT INCREASED TO AMOUNT OF DEDUCTIBLE AND 
                   OUT-OF-POCKET LIMITATION.

       (a) Self-Only Coverage.--Section 223(b)(2)(A) of the 
     Internal Revenue Code of 1986 is amended by striking 
     ``$2,250'' and inserting ``the amount in effect under 
     subsection (c)(2)(A)(ii)(I)''.
       (b) Family Coverage.--Section 223(b)(2)(B) of such Code is 
     amended by striking ``$4,500'' and inserting ``the amount in 
     effect under subsection (c)(2)(A)(ii)(II)''.
       (c) Conforming Amendments.--Section 223(g)(1) of such Code 
     is amended--
       (1) by striking ``subsections (b)(2) and'' both places it 
     appears and inserting ``subsection'', and
       (2) in subparagraph (B), by striking ``determined by'' and 
     all that follows through `` `calendar year 2003'.'' and 
     inserting ``determined by substituting `calendar year 2003' 
     for `calendar year 1992' in subparagraph (B) thereof .''.
       (d) Effective Date.--The amendments made by this section 
     shall apply to taxable years beginning after December 31, 
     2017.

     SEC. 216. ALLOW BOTH SPOUSES TO MAKE CATCH-UP CONTRIBUTIONS 
                   TO THE SAME HEALTH SAVINGS ACCOUNT.

       (a) In General.--Section 223(b)(5) of the Internal Revenue 
     Code of 1986 is amended to read as follows:
       ``(5) Special rule for married individuals with family 
     coverage.--
       ``(A) In general.--In the case of individuals who are 
     married to each other, if both spouses are eligible 
     individuals and either spouse has family coverage under a 
     high deductible health plan as of the first day of any 
     month--
       ``(i) the limitation under paragraph (1) shall be applied 
     by not taking into account any other high deductible health 
     plan coverage of either spouse (and if such spouses both have 
     family coverage under separate high deductible health plans, 
     only one such coverage shall be taken into account),
       ``(ii) such limitation (after application of clause (i)) 
     shall be reduced by the aggregate amount paid to Archer MSAs 
     of such spouses for the taxable year, and
       ``(iii) such limitation (after application of clauses (i) 
     and (ii)) shall be divided equally between such spouses 
     unless they agree on a different division.
       ``(B) Treatment of additional contribution amounts.--If 
     both spouses referred to in subparagraph (A) have attained 
     age 55 before the close of the taxable year, the limitation 
     referred to in subparagraph (A)(iii) which is subject to 
     division between the spouses shall include the additional 
     contribution amounts determined under paragraph (3) for both 
     spouses. In any other case, any additional contribution 
     amount determined under paragraph (3) shall not be taken into 
     account under subparagraph (A)(iii) and shall not be subject 
     to division between the spouses.''.
       (b) Effective Date.--The amendment made by this section 
     shall apply to taxable years beginning after December 31, 
     2017.

     SEC. 217. SPECIAL RULE FOR CERTAIN MEDICAL EXPENSES INCURRED 
                   BEFORE ESTABLISHMENT OF HEALTH SAVINGS ACCOUNT.

       (a) In General.--Section 223(d)(2) of the Internal Revenue 
     Code of 1986 is amended by adding at the end the following 
     new subparagraph:
       ``(D) Treatment of certain medical expenses incurred before 
     establishment of account.--If a health savings account is 
     established during the 60-day period beginning on the date 
     that coverage of the account beneficiary under a high 
     deductible health plan begins, then, solely for purposes of 
     determining whether an amount paid is used for a qualified 
     medical expense, such account shall be treated as having been 
     established on the date that such coverage begins.''.
       (b) Effective Date.--The amendment made by this section 
     shall apply with respect to coverage beginning after December 
     31, 2017.

              Subtitle B--Repeal of Certain Consumer Taxes

     SEC. 221. REPEAL OF TAX ON PRESCRIPTION MEDICATIONS.

       Subsection (j) of section 9008 of the Patient Protection 
     and Affordable Care Act is amended to read as follows:
       ``(j) Repeal.--This section shall apply to calendar years 
     beginning after December 31, 2010, and ending before January 
     1, 2017.''.

     SEC. 222. REPEAL OF HEALTH INSURANCE TAX.

       Subsection (j) of section 9010 of the Patient Protection 
     and Affordable Care Act is amended to read as follows:
       ``(j) Repeal.--This section shall apply to calendar years 
     beginning after December 31, 2013, and ending before January 
     1, 2017.''.

                   Subtitle C--Repeal of Tanning Tax

     SEC. 231. REPEAL OF TANNING TAX.

       (a) In General.--The Internal Revenue Code of 1986 is 
     amended by striking chapter 49.
       (b) Effective Date.--The amendment made by this section 
     shall apply to services performed after June 30, 2017.

             Subtitle D--Remuneration From Certain Insurers

     SEC. 241. REMUNERATION FROM CERTAIN INSURERS.

       Paragraph (6) of section 162(m) of the Internal Revenue 
     Code of 1986 is amended by adding at the end the following 
     new subparagraph:
       ``(I) Termination.--This paragraph shall not apply to 
     taxable years beginning after December 31, 2016.''.

            Subtitle E--Repeal of Net Investment Income Tax

     SEC. 251. REPEAL OF NET INVESTMENT INCOME TAX.

       (a) In General.--Subtitle A of the Internal Revenue Code of 
     1986 is amended by striking chapter 2A.
       (b) Effective Date.--The amendment made by this section 
     shall apply to taxable years beginning after December 31, 
     2016.

  The SPEAKER pro tempore. The bill shall be debatable for 4 hours 
equally divided and controlled by the chair and ranking minority member 
of the Committee on the Budget or their respective designees.
  The gentlewoman from Tennessee (Mrs. Black) and the gentleman from 
Kentucky (Mr. Yarmuth) each will control 2 hours.
  The Chair recognizes the gentlewoman from Tennessee.


                             General Leave

  Mrs. BLACK. Mr. Speaker, I ask unanimous consent that all Members 
have 7 legislative days in which to revise and extend their remarks on 
H.R. 1628, the American Health Care Act of 2017.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentlewoman from Tennessee?
  There was no objection.
  Mrs. BLACK. Mr. Speaker, I yield myself such time as I may consume.
  I rise today to speak in favor of the American Health Care Act, a 
bill that repeals many of the worst aspects of ObamaCare, and begins to 
repair the damage caused by the law by bringing choice, competition, 
and patient-centered solutions back into our healthcare system.
  Standing here today in the House debating this bill is a proud moment 
for me. I was working as a nurse in Nashville in the 1990s when, fresh 
off of the failure of HillaryCare, the Clinton administration pushed 
out a single-payer pilot program in Tennessee called TennCare.
  As the story goes, Vice President Gore and the Democratic Governor 
sketched out a program on a napkin while sitting in a local bar. I saw 
firsthand the negative impact of government-run health care on patient 
care. I saw the costs rise, and the quality of care fall. I saw the 
burdens being placed on doctors, patients, hospitals, and care 
providers. I saw patients faced with fewer choices and more regulation. 
And I saw the devastating impact that TennCare was having on our 
State's budget, gobbling up so much State spending that other 
priorities like education and infrastructure were getting squeezed.
  I couldn't sit idly by while this was happening in my State, so I 
decided to get involved in public service, and it is what inspired me 
to run for office at the very beginning. And when, in 2009 and 2010, I 
saw the same principles being debated and eventually implemented on the 
national level, I thought my experience in Tennessee would be valuable 
to the national debate. I told the people in my district that, if 
elected to Congress, I would fight to repeal and replace ObamaCare.
  In 2011, I sponsored the first piece of legislation that repealed a 
part of ObamaCare. And today, we take the largest step yet in rescuing 
the American people from the damage that has been done by ObamaCare.
  We are united in our goal to repeal ObamaCare and replace it with 
patient-centered health care. Right now, ObamaCare is imploding. We 
were promised premiums that would decrease by $2,500; instead, average 
family premiums in the employer market have soared by $4,300.
  We were promised healthcare costs would go down; instead, deductibles 
have skyrocketed.

[[Page H2406]]

  We were promised we could keep our doctor, and keep our health 
insurance plans; instead, millions of Americans have lost their 
insurance and the doctors that they liked.
  In short, the Affordable Care Act was neither affordable, nor did it 
provide the quality of care that the American people deserve.
  The American Health Care Act is a first step in our efforts to 
deliver patient-centered healthcare reform. This bill returns to the 
American people freedom and choice in their healthcare decisions. It 
gets government out of the relationship between patients and their 
doctors--where it has never belonged--and puts people back in charge of 
their own health care. It brings the free market principle of 
competition to an industry that has long been dominated by government 
intervention.
  Today we are faced with a stark choice: Do we vote to continue the 
damage ObamaCare is doing to our country and our constituents, or do we 
vote to go down another path, a better way of doing health care in this 
country?
  While no legislation is perfect, this bill does accomplish some 
important reforms. It zeros out the mandates. It repeals taxes. It 
repeals the subsidies. It allows people to choose health insurance 
plans that are unique to their families, instead of purchasing a one-
size-fits-all plan that is mandated by some Washington bureaucrat, and 
it modernizes Medicaid, a once-in-a-lifetime entitlement reform.
  Ending Medicaid's open-ended funding structure will play an important 
role in addressing the future budget deficits and our growing national 
debt. I applaud my colleagues who have stayed in this fight and 
continue to make this bill better.
  The members of the Budget Committee, which I chair, outlined four 
principles they believed would improve the bill. Those principles led 
to significant changes to allow more State flexibility in Medicaid and 
ensure that tax credits truly served the people they are meant to 
serve.
  Others fought to eliminate Federal ObamaCare regulations that drive 
up the cost of health care for all Americans and give those powers back 
to the States. At the same time, we also ensure that States have the 
resources to provide maternity and newborn care and treatment for 
mental health and substance abuse.
  I agree with these changes, and I applaud my colleagues for the work 
to make sure that we truly reverse the damage ObamaCare is doing to our 
healthcare system and our economy.
  ObamaCare's legacy is clear: more government, less choice, and higher 
costs. Our vision for health care in America is the opposite: more 
freedom, more choice, and lower costs. Put simply, the American Health 
Care Act is a good first step, but it is only a first step.
  My good friend and our former colleague, Dr. Tom Price, will use his 
position as Secretary of Health and Human Services to address some of 
the regulatory burden of ObamaCare through administrative action. We 
have voted already and will continue to vote on individual pieces of 
legislation to implement even more patient-centered, free market 
reforms that we cannot address through reconciliation.

  In fact, we just passed two bills already this week. One would allow 
small businesses to join together to purchase insurance, and the other 
would increase competition by tearing down antitrust regulations. That 
bill received 416 votes. This shows that these bills are commonsense 
measures that include bipartisan support.
  The day is finally here where we have an opportunity to fulfill that 
promise that we have made to the American people. I, for one, cannot 
sit idly by and let this opportunity go to waste. Campaigning is easy 
compared to governing, but our constituents did not elect us to do what 
is easy. They elected us to do what is right.
  I urge my colleagues to join me in voting ``yes'' on the American 
Health Care Act, to rescue the American people from ObamaCare.
  Mr. Speaker, I reserve the balance of my time.
  Mr. YARMUTH. Mr. Speaker, I yield myself such time as I may consume.
  Mr. Speaker, after 7 years of campaigning against the Affordable Care 
Act, congressional Republicans have finally produced what they 
cynically describe as a replacement plan.
  Sadly, however, this bill will unravel all of the progress we made 
under the ACA, including expanding access to health insurance to 22 
million Americans and improving the quality of coverage and care for 
tens of millions more.
  It nearly doubles the amount of uninsured people in this country, 
guts Medicaid by almost $900 billion, and weakens the Medicare trust 
fund.

                              {time}  1130

  That was bad enough. But the last-minute changes to this bill are 
astonishing and appalling. This legislation now allows insurers to end 
coverage for prescription drugs, mental health, maternity and newborn 
care, preventive care, emergency room visits, hospitalizations, 
outpatient care, rehab visits, lab services, and pediatric care. That 
is not progress. That is not a fix. That is a potential health crisis 
for every American.
  My Republican colleagues are well aware of this. Why else would they 
have drafted this bill and these last-minute changes in secret? Why 
else would complicated legislation affecting the lives of millions be 
sent to the floor just 2 weeks after it was introduced with no 
congressional hearings, not a single one, on a bill that impacts the 
health care of nearly every American family? Why else would they rush 
the bill to the floor without an updated Congressional Budget Office 
estimate of how much coverage and care will be lost by their backroom 
deal that ends consumer protections?
  I get it. I wouldn't want to, nor would I know how to justify giving 
nearly $1 trillion in tax cuts to corporations and the wealthy paid for 
by threatening the health and well-being of millions of American 
families.
  Who is getting these huge windfalls?
  Companies like Amgen, with annual profits of more than $3 million; 
Medtronic, with annual profits of more than $6 billion; and Gilead 
Sciences, with $13 billion in profits in 2016 alone.
  When the CBO released its report last week showing that 24 million 
hardworking Americans will be left without healthcare coverage by 2026 
if we pass this bill, that premiums will rise 15 to 20 percent next 
year, that people will pay thousands of dollars more in deductibles and 
out-of-pocket costs, and that older Americans will be priced out of the 
market by an age tax, I thought for sure it was dead on arrival, that 
there was no way my Republican colleagues would walk this plank. But 
here they are, and they are trying to take millions of American 
families with them.
  Fourteen million Americans will lose health coverage next year if 
this bill is approved. Twenty-one million Americans will lose coverage 
in the next 3 years alone, wiping out all of the coverage gains from 
the ACA in just 3 years. For pretty much everyone else in the 
individual market, deductibles and other costs will be higher. And for 
lower-income individuals, out-of-pocket costs will be much higher.
  Insurance companies will again be able to sell plans that offer much 
less financial protection, and we will return to the days when millions 
of people in this country will live in fear that they are always one 
serious illness or accident away from bankruptcy.
  This bill will result in the largest transfer of wealth from 
struggling families to the well-off in our Nation's history, giving $1 
trillion in tax breaks to millionaires, billionaires, and corporations. 
It is Robin Hood in reverse, but this is far worse because access to 
lifesaving care is being stolen.
  I don't say that casually. I have met people, constituents of mine, 
whose lives have been saved because of the Affordable Care Act.
  This is from one of my constituents:
  ``My name is Kevin Schweitzer. I am 62 years old and I'm a lifelong 
resident of Louisville, Kentucky.
  ``I worked hard, took risks and built a successful small business 
that I sold at age 59. My wife and I were excited about our prospects 
as we headed into early retirement. As a retiree too young for 
Medicare, I purchased health insurance on the open market. Less than a 
year later, I was diagnosed with lymphoma. I have undergone multiple 
scans and 2 cycles of chemo. I am winning the battle so far, but since 
this disease is in my blood I will be fighting it for the rest of my 
life.

[[Page H2407]]

  ``A cancer diagnosis is a life-changing event that not only attacks 
the body, but the mental stress is just as tough to deal with. Thanks 
to ObamaCare, I've been able to rest easier knowing that my illness 
wouldn't bankrupt my family and that I'll be able to provide for my 
wife even after I'm gone.''
  I also heard from a young woman named Sarah Adkins. She suffers from 
chronic kidney disease. Sarah was able to get health insurance because 
of the ACA. On January 9, 2011, it saved her life. One of her kidneys 
shut down and almost went septic. If she didn't have coverage, she 
would have waited or not gone to the hospital at all. The doctor told 
her that if she had arrived at the ER an hour later, she would have 
died.
  Mr. Speaker, the health of my constituents Kevin Schweitzer and Sarah 
Adkins is at stake in this debate. They, and the hundreds of other 
constituents I have heard from who have serious and chronic health 
conditions, will need high-quality, affordable health coverage for the 
rest of their lives. Under this bill, they will get less coverage, it 
will cost more, and eventually they will be priced out of the market, 
leaving them nowhere to turn for the care they need.
  And that is not all. Because of the last-minute changes to this bill, 
insurers will be able to sell stripped-down coverage to weed out people 
with preexisting conditions. They will be able to refuse, for example, 
to offer coverage for chemotherapy drugs and cancer treatments, insulin 
pumps, hospital stays, and prescription drugs that treat chronic 
conditions across the board. Basically, if you have a serious health 
problem, the care you need may not be available to you at all.
  When the American people were promised by President Trump and 
Republican congressional leadership that their existing coverage would 
be preserved and that everybody would have insurance and it would be 
less expensive and much better, they, understandably, believed they 
would be treated much better than this. None of those promises are in 
this bill. In fact, the opposite of every one of those promises is what 
is in this bill. Those were promises made to every family in our 
congressional districts, and this bill fails them at every turn.
  Mr. Speaker, I urge my colleagues to oppose this legislation, and I 
reserve the balance of my time.
  Mrs. BLACK. Mr. Speaker, I yield 2 minutes to the gentleman from 
California (Mr. McClintock).
  Mr. McCLINTOCK. Mr. Speaker, I remind the gentleman from Kentucky 
that every promise made to the American people in support of ObamaCare 
was rapidly broken. We are now, at this moment in time, watching the 
death throes of ObamaCare.
  More people are paying the State tax penalty or claiming hardship 
exemptions than are buying ObamaCare policies. In a third of our 
counties, there is no choice left at all. You get one provider. Soon, 
we are warned, some regions will have no providers at all. Premiums 
soared an average of 25 percent last year, and this year we are warned 
it could be 40 percent or more.
  Critics cite the CBO estimate that 24 million Americans will lose 
their coverage. It is important to understand their reasoning there. 
The CBO believes that people won't buy health insurance unless we force 
them to buy health insurance. In fact, people won't buy health 
insurance that is not a good value for them, and, clearly, ObamaCare 
isn't.
  We replace it with a vigorous buyer's market where plans across the 
country will compete to offer consumers better services at lower prices 
tailored to their own needs and wants. And we assure these plans are 
within their financial reach with $90 billion of additional support 
that the CBO simply ignores.
  The AHCA's biggest achievement is to replace coercion with choice for 
every American. It ends the individual mandate that forces Americans to 
buy products they don't want. It ends the employer mandate that has 
trapped many low-income workers in part-time jobs. It begins to restore 
consumers' freedom of choice, the best guarantee of quality and value 
in any market. It allows Americans to meet more of their healthcare 
needs with pretax dollars. It relieves the premium base of the enormous 
cost of preexisting conditions by moving them to a block-granted 
assigned risk pool.
  Mr. Speaker, ObamaCare is collapsing, premiums are skyrocketing, and 
providers are fleeing. This may well be our last off-ramp on this road 
to ruin.
  Mr. YARMUTH. Mr. Speaker, I remind my colleague that his vote for 
this bill will result in 38,200 people from his congressional district 
in California losing health care and coverage.
  Mr. Speaker, I yield 1\1/2\ minutes to the gentlewoman from 
California (Ms. Lee), a distinguished member of the Budget Committee.
  Ms. LEE. Mr. Speaker, I rise in strong opposition to H.R. 1628, which 
is a bill to take away health care from 24 million Americans.
  Whether you believe it or not, health care is a basic right. This 
shameful bill steals from those who can least afford it, including 
seniors, veterans, people living with HIV, children, and the disabled. 
It would, yes, rip away health care from 24 million people. It would 
reduce benefits, make families pay more for less, and transfer $600 
billion in tax cuts to the very wealthy. This is outrageous.
  Access to women's health is denied by defunding Planned Parenthood. 
Medicaid, as we know it, will end. Healthcare costs for working 
families and seniors will skyrocket. And now it eliminates essential 
health benefits like maternity, mental health, and emergency care.
  This is not a health bill. It is a tax giveaway to the wealthy.
  Let me tell you, as a woman of faith, I am appalled and I am saddened 
by the hypocrisy displayed in this bill by people who say they are 
religious. I want to remind you--in the Scriptures, the Book of Mark, 
chapter 12:31, we are reminded to love your neighbor as yourself.
  This bill shows disdain for the most vulnerable and would lead to 
death and destruction and disease for millions of Americans.
  I hope Republicans remember to love their neighbor as themselves 
today and vote ``no'' on this mean-spirited bill. Let's defeat this 
harmful and morally bankrupt bill. This is a matter of life and death, 
and the American people deserve better.
  Mrs. BLACK. Mr. Speaker, I yield 2 minutes to the gentleman from Ohio 
(Mr. Johnson), a member of the Budget Committee.
  Mr. JOHNSON of Ohio. Mr. Speaker, the American people spoke loudly 
and clearly last November. In fact, they have been speaking loudly and 
clearly ever since this fatally flawed bill called ObamaCare was signed 
into law. And now we are hours away from the vote that the American 
people have been waiting years for.
  This vote can be distilled down to simply this, and each Member of 
this body must ask themselves this simple question: Are they willing to 
allow ObamaCare to remain the law of the land? Or are we going to begin 
to restore healthcare decisions to the American people and their 
doctors?
  Those who choose to vote against the American Health Care Act, 
regardless of how they attempt to justify it, will be voting to keep 
ObamaCare in place. This is an inescapable fact that will remain long 
after the smoke and spin and handwringing from political pundits 
following this vote has gone and disappeared, regardless of how the 
votes go.
  There is no such thing as perfect legislation in a body of 435 men 
and women representing 435 different parts of the Nation.
  There is consensus among the American people that this law should be 
repealed and replaced, and today the people's House will either 
acknowledge the will of the people or we will defy it.
  Mr. YARMUTH. Mr. Speaker, I remind my colleague that his vote for 
this bill will result in 40,500 people from his congressional district 
in Ohio losing health coverage and care.
  Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from 
Massachusetts (Mr. Moulton), a distinguished member of the Budget 
Committee.
  Mr. MOULTON. Mr. Speaker, I would also like to remind the gentleman 
from Ohio that the latest poll put the will of the American people at 
17 percent in favor of this bill.
  I would like to read a message from my Republican constituent:
  ``The American Health Care Act would strain the fiscal resources 
necessary to support the Commonwealth's

[[Page H2408]]

continued commitment to universal health coverage.''
  This constituent is the Republican Governor of Massachusetts, who 
knows that TrumpCare destroys our ability to ensure access to quality, 
affordable healthcare coverage.
  Another Republican in my State, Governor Mitt Romney, worked with the 
Democratic legislature to create the Nation's first system to provide 
affordable, comprehensive health care. RomneyCare wasn't perfect, but 
Republicans and Democrats worked together to improve it, and they 
created a system with higher approval ratings than TrumpCare or even 
ObamaCare.
  We can do this. Health care should not be partisan. It should be 
about investing in our people, in our families, and in our future so 
that Americans can live healthy, productive lives. But that is not what 
this Republican TrumpCare bill does.
  Michael is a constituent from Gloucester, the old fishing city. He 
was prescribed OxyContin by his doctors, and then became addicted. But 
he was able to enter a treatment program through Medicaid, the kind of 
program that will be cut by TrumpCare. He is now back at work as an 
electrician, and he says that the Affordable Care Act saved his life.
  I am a veteran, and I get my health care at the VA. Sometimes it 
takes me weeks to get an appointment. If this Republican bill passes, 
it will throw 8 million veterans off private health care, forcing them 
into the VA, and creating even longer wait times. That is no way to 
treat those who have put their lives on the line for our country.
  Perhaps it's no surprise that this bill is being jammed down the 
throats of Congress and the American people like a dead fish.
  Nobody wants it and it will make a lot of people sick.
  What we should be doing here in Washington is coming together as 
Republicans and Democrats to have an open, honest debate, and improve 
the health care system.
  Everyone says Congress doesn't work--don't prove them right.
  I urge my colleagues to vote no on this terrible bill and to instead 
come to the table like we did in Massachusetts.
  Mrs. BLACK. Mr. Speaker, I yield 2 minutes to the gentleman from 
Minnesota (Mr. Lewis), who is a distinguished member of the Budget 
Committee.

                              {time}  1145

  Mr. LEWIS of Minnesota. Mr. Speaker, I rise today in support of the 
American Health Care Act, and I ask the other side: Just what is it you 
are trying to preserve by voting ``no?''
  Premiums rising double digits for years for the last 7 years? In my 
home State of Minnesota, back-to-back premium increases of 50 to 67 
percent?
  Young, healthy people being priced out of the insurance market, 8 
million in 2014, choosing to pay the penalty instead of buying 
insurance?
  That is the genesis of the death spiral in the insurance markets. 
That is what this bill is trying to correct.
  Deductibles, copays--I had a deductible on my own individual policy, 
a skyrocketing deductible. There are deductibles of $13,000. That is 
not health care. That is not even access.
  Drug formularies being tightened to save money, so people are denied 
prescription drugs, a prescription drug tax; thousands of Minnesotans 
losing their plans, 100,000 when a big insurer dropped out; 1,000 
counties with one insurer--that is what you are trying to preserve on 
the other side, people voting ``no'' on this bill?
  Emergency State legislation trying to prop up MNsure in my home State 
because it is failing, and $1 trillion in taxes and spending that is 
bankrupting the country--that is what the other side is trying to 
preserve.
  Those voting ``no'' on this bill, we have a choice today. You can 
embrace the status quo and see the markets spiral out of control 
completely, or you can vote for change and do the right thing.
  Mr. YARMUTH. Mr. Speaker, I remind my colleague that his vote for 
this bill will result in 50,200 people from his congressional district 
in Minnesota losing health coverage and care.
  I yield 1\1/2\ minutes to the gentleman from New York (Mr. Jeffries), 
a distinguished member of the Budget Committee.
  Mr. JEFFRIES. Mr. Speaker, the Trump Presidency has been 
characterized by chaos, crisis, and confusion, and this Republican 
healthcare debacle has been no different.
  The American people clearly understand that TrumpCare will be an 
unmitigated disaster. Under TrumpCare, working families will pay more 
and get less. Under TrumpCare, premiums will increase. Under TrumpCare, 
copays will increase. Under TrumpCare, deductibles will increase. Under 
TrumpCare, out-of-pocket expenses will increase.
  Under TrumpCare, 24 million hardworking Americans will lose their 
health coverage. Under TrumpCare, individuals between the age of 50 and 
64 will pay a regressive age tax.
  Health care is a matter of life and death; that is why we take it so 
seriously. TrumpCare will lead to increased death, disease, and 
destitution, and that is why we oppose this horrible piece of 
legislation.
  Mrs. BLACK. Mr. Speaker, I yield 2 minutes to the gentleman from 
Texas (Mr. Arrington) who is a member of the Budget Committee.
  Mr. ARRINGTON. Mr. Speaker, ObamaCare's disastrous effects over the 
last several years have wreaked havoc on our small businesses, broken 
the backs of middle and working class families, and have had a 
disproportionately negative impact on rural America. Those are the 
folks who I represent in west Texas.
  While the current bill before us is far from perfect--and let's be 
honest, there is no such thing as perfect legislation--it reverses 
course and takes us in the right direction. It repeals the mandates and 
restores freedom to individuals and markets.
  It repeals about $1 trillion of taxes. It reduces deficit spending by 
over $100 billion, making it the largest entitlement reform since the 
1960s. It rolls back regulations, gives maximum flexibility to States, 
and begins to defederalize health care.
  For 7 years now, Republicans have promised the American people that 
if we were given control of the Presidency and the House and the 
Senate, then we would repeal and replace ObamaCare. And now that we are 
given the opportunity to govern and to keep our promises and to deliver 
results for the American people, we can't let perfect be the enemy of 
good.
  The debate is now closing. We have two choices. We either pass a good 
but imperfect bill, or we leave ObamaCare in place. That is an 
unacceptable alternative.
  As leaders, we have a moral obligation to do something, to not stand 
idly by while the people suffer under a system that is failing them.
  If we are going to restore the greatness of America and transfer 
power back to the people, we need more than policy solutions, even 
perfect policy solutions. We need the political will and the courage to 
lead.
  This is a rescue mission, Mr. Speaker, and it isn't without risk; but 
I have faith in the President and his team. I have faith in our States 
and the free markets, and, above all, Mr. Speaker, I have faith in the 
American people.
  Mr. YARMUTH. Mr. Speaker, I remind my colleague that his vote for 
this bill will result in 60,400 people from his congressional district 
in Texas losing health coverage and care.
  I yield 2 minutes to the gentleman from New York (Mr. Higgins), a 
distinguished member of the Budget Committee and the Ways and Means 
Committee.
  Mr. HIGGINS of New York. Mr. Speaker, this never needed to be an 
ideological fist fight. Democrats were always willing to take into 
account serious and constructive alternatives to the law that we have 
today that make it better, to make it affordable, more affordable for 
the American people.
  But this bill is a blatant takeaway from the American people of money 
and protection. If you are 50 to 64 years old, you get clobbered. If 
you are 64 years old, you make $26,000 a year, according to the 
Republican-led Congressional Budget Office, your premiums go from 
$1,700 a year to $14,000 a year.
  Fact: UnitedHealthcare is one of the largest private health insurers 
in America.
  Fact: UnitedHealthcare will have $200 billion in revenues this year, 
and they paid their chief executive officer $66 million in compensation 
in 2014.

  Fact: UnitedHealthcare is under investigation today by the Department 
of Justice for stealing billions of dollars from the Medicare program.

[[Page H2409]]

  Fact: The Republican health bill, on page 67, in 7 words, gives 
UnitedHealthcare, their high-paid executives, and all of their cronies, 
a massive tax cut to continue to screw the American people.
  Mr. Speaker, we can do much better. We are prepared to do much 
better. But this is a financial assault on good, hardworking Americans 
who want to do one thing at the end of the day, after paying too much 
money for health care throughout the year, and that is, when they need 
their health care, it is available to them and their family.
  Mrs. BLACK. Mr. Speaker, I yield 2 minutes to the gentleman from New 
York (Mr. Faso), a distinguished member of the Budget Committee.
  Mr. FASO. Mr. Speaker, I wanted to point out to my colleagues that a 
fundamental change is being made with the new health law we have before 
us, and that is, we are, for the first time, equalizing the treatment 
of people who do not have employer-provided health care.
  Those of us who have employer-provided health care, 170 million 
Americans, that is not a taxable event for them. It is not a taxable 
event where they have to pay tax at the end of the year on the value of 
that employer-provided health care.
  And yet, if you are the person who does not have employer-provided 
health care, if you are the husband and wife with two kids making 45 or 
$50,000, and your employer does not provide health care, you receive 
absolutely no tax subsidy through the Tax Code.
  This bill, through the advance refundable tax credits, will, for the 
first time, give someone the choice to buy health care and give them 
the opportunity and the means to buy health care that they previously 
have not had. It is not a markedly important distinction, frankly, from 
the Affordable Care Act, where you only could buy the health care 
through an exchange-approved policy.
  This policy, under this legislation today, will allow someone the 
flexibility and the freedom to buy a policy of their choosing, not one 
dictated by Washington. So that is a fundamental important distinction 
between the status quo and what this legislation would offer.
  Mr. Speaker, and my colleagues, I urge support for the bill. It is 
not perfect, as we all know, but it is something that is long overdue.
  I would also point out that the numbers that my colleague from 
Kentucky uses are really based upon fantasy. Those numbers are simply 
incorrect, and the people of our State and our country will have health 
care under the provisions of this bill, and we will work hard to ensure 
that they do.
  Mr. YARMUTH. Mr. Speaker, I remind my colleague that his vote for 
this bill will result in 65,800 people from his congressional district 
in New York losing health coverage and care.
  I yield 2 minutes to the gentlewoman from Washington (Ms. DelBene), a 
distinguished member of the Budget Committee and the Ways and Means 
Committee.
  Ms. DelBENE. Mr. Speaker, if Republicans crafted legislation that 
lived up to the promise of insurance for everybody, they would have 
broad bipartisan support. But that is not what they did.
  This bill threatens massive disruption and chaos, not only to our 
healthcare system, but to middle class families, families who sit at 
their kitchen table trying to figure out how to pay their mortgage, buy 
groceries, and also get health coverage for their kids. This Republican 
bill does nothing to help them.
  In their rush to check a political box, Republicans have crafted 
legislation that does nothing but hurt working Americans, and, in the 
last 24 hours, it has gone from bad to worse.
  Make no mistake, the changes made in the 11th hour to appease the 
most extreme Members of Congress have put lifesaving care even further 
out of reach.
  Some may use alternative facts, but this is reality, and the reality 
is that their bill robs $75 billion from Medicare, forces older 
Americans to pay five times more than others, and shifts $312 billion 
in out-of-pocket costs onto middle class families.
  But this is about more than numbers. It is about people like Rachel, 
from Kirkland, Washington, who suffered a heart attack and blood clot 
at the age of 35. She now depends on frequent tests, medications and 
doctors' visits to stay healthy. Thankfully, it is all covered by her 
insurance.
  Rachel told me: ``I'm horrified by the talking point that equates 
repealing the Affordable Care Act with getting freedom back. For me, 
the loss of the ACA gives me nothing but the freedom to die sooner and 
worry more.''
  I am not voting against this bill because it is a Republican bill. I 
am voting ``no'' for families like Rachel's.
  Health care doesn't need to be a partisan issue, and I stand ready 
and willing to work on commonsense solutions that expand coverage and 
reduce costs. But I was sent here to make my constituents' lives 
better. This bill does not do that. I encourage my colleagues to vote 
``no.''
  Mrs. BLACK. Mr. Speaker, I yield 2 minutes to the gentleman from 
Florida (Mr. Gaetz) who is a distinguished member of our Budget 
Committee.
  Mr. GAETZ. Mr. Speaker, I rise to repeal the disaster that is 
ObamaCare. ObamaCare functions as a wet blanket over the American 
economy, stopping businesses from growing, and impairing the rights of 
individuals to make their own decisions about health care.
  Mr. Speaker, I specifically implore my conservative colleagues to 
vote for this bill and give us a chance to get out from under this 
disastrous law. This legislation represents $1 trillion in tax cuts, 
$1.15 trillion in spending cuts, $150 billion in deficit reduction; 
defunding Planned Parenthood.
  How long have we been fighting to defund Planned Parenthood?
  Close the illegal alien loophole that allows people to enroll in 
ObamaCare, only to check their status in this country subsequently.
  We install work requirements. I don't think people that are able to 
work but choose not to should expect us to go borrow money from China 
to pay for their health care. Installing those work requirements is 
fundamental to bold conservative reform.
  Block grants for States so that finally they can be liberated from 
the oppressive hand of the Federal Government, and also blocking States 
from additional Medicaid expansion.
  We have been engaging in these conservative fights for years, and 
finally, today, we have got the chance to put a win on the board; and 
so I am joining our President, our Speaker, and many conservatives in 
this Congress in voting for the American Health Care Act.
  When we win, when we do this, not only do we enhance our economy, not 
only do we free up opportunities for broader prosperity in America, but 
we allow people to be in charge of health care, and we move from a 
government-centered system to a patient-centered system. That was the 
promise we made in the elections, and that is the promise I intend to 
keep by voting for this bill.
  Mr. YARMUTH. Mr. Speaker, I remind my colleague that his vote for 
this bill will result in 56,000 people from his congressional district 
in Florida losing health coverage and care.
  I yield 1\3/4\ minutes to the gentlewoman from Florida (Ms. Wasserman 
Schultz), a distinguished member of the Budget Committee.

                              {time}  1200

  Ms. WASSERMAN SCHULTZ. Mr. Speaker, I stand in opposition to the 
Republican pay more for less care act, under which Americans will 
suffer from higher healthcare costs, less coverage, a crushing age tax, 
and a ransacking of the Medicare trust fund, which our seniors depend 
on for long-term care.
  Under the age tax, Americans aged 50 to 64 will be forced to pay five 
times higher premiums than others, no matter how healthy they are. 
Under TrumpCare, a 64-year-old with an income of $26,500 in the 
individual market will pay $12,900 more in their premiums every year 
under this bill.
  In addition, TrumpCare will take away health care from 24 million 
hardworking Americans and will force families to pay higher premiums 
and deductibles. In fact, for families enrolled in the ACA marketplace, 
premiums are expected to increase by 15 to 20 percent.
  It will also punish millions of people who experience a lapse in 
coverage by forcing them to pay a 30 percent higher premium each month 
in order to receive care.

[[Page H2410]]

  Tell that to Suzanne Boyd from Sunrise, Florida, who, with two 
daughters heading to college, lost her husband to lung cancer and then 
lost the insurance coverage she had through her employer. Thankfully, 
she was able to obtain coverage under the ACA for $192 a month with 
subsidies rather than a 30 percent Republican sick tax for getting a 
life-threatening illness.
  Yet this bill apparently isn't harmful enough for the far-right 
extremists in the Republican Party, whom Republican leadership has 
tried to appease by cutting the ACA essential health benefits like 
mental health, maternity, and emergency services.
  Mr. Speaker, this bill is like taking a sledgehammer to a clock that 
is moving a little slow rather than working on precision fine tuning 
instead. It is an immoral piece of legislation. As a breast cancer 
survivor, I urge every Member to stand with my sister survivors all 
across the country, who number in the millions, to make sure that you 
don't devastate our health and make sure that we don't have our lives 
threatened.
  Mrs. BLACK. Mr. Speaker, I yield 2 minutes to the gentleman from 
Indiana (Mr. Rokita), who is the vice chair of the Budget Committee.
  Mr. ROKITA. Mr. Speaker, I thank the chairwoman.
  I am really proud, Mr. Speaker, of the Budget Committee. We did great 
work last week, and everyone was heard: six motions on the Republican 
side, six motions on the Democratic side, and the debate was civil. 
Tones weren't raised; theatrics, by and large, weren't employed; and we 
made the bill better. That was the process the week before that when 
the committees of jurisdiction had this legislation.
  It is my hope that, as we pass this bill off the floor of the House--
and it is a bill being passed off the floor of the House and not into 
law right now--and as it goes to the Senate, that the bill will 
continue to be improved. That is the legislative process.
  I am very proud of the members of the staff of the Budget Committee 
for being a major part of that process and starting that process. We 
did good work. You don't have to pass this bill to find out what is in 
it as we had to with ObamaCare. This process will continue.
  I am very pleased, also, that we have Medicaid block grants, or lump 
sum payments to the States, that are available now to cover at least 
our able-bodied children and adults. It is a huge step forward in 
letting States have the flexibility they need to decide who really 
needs this assistance, how they should get it, and what they should get 
in terms of health care.
  This is good legislation. This is what we were sent to do, and we are 
keeping our promises to the American people by passing this 
legislation.
  Mr. Speaker, I urge all my colleagues to vote ``yes.''
  Mr. YARMUTH. Mr. Speaker, I remind my friend from Indiana that his 
vote for this bill will result in 37,900 people from his congressional 
district losing health coverage and care.
  Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from 
Pennsylvania (Mr. Brendan F. Boyle), who is a distinguished member of 
the Budget Committee.
  Mr. BRENDAN F. BOYLE of Pennsylvania. Mr. Speaker, I rise today in 
opposition to TrumpCare, the Republican plan to cut Medicare and 
Medicaid, increase healthcare costs, and take health care away from 
tens of millions of Americans, all while providing the largest transfer 
of wealth from working families to our Nation's richest, and all of 
this in the name of choice and freedom. But we all know that, under 
this bill, that is just code for survival of the fittest, economic 
Darwinism.
  Mr. Speaker, let me bring this a little closer to home for me. Thanks 
to TrumpCare, 36,700 of my constituents covered by the ACA's Medicaid 
expansion now stand to lose this lifesaving coverage. Here is one of 
them, constituent Maura McGrath, a 17-year-old with Down syndrome.
  Maura's parents, Joe and Rita, know firsthand why Medicaid is so 
important. Medicaid has been critical to keeping their daughter alive 
and saving their family from bankruptcy. Even though Joe and Rita both 
work, the cost of Maura's care is too expensive to afford on their own, 
not to mention that Rita is a breast cancer survivor and Joe suffers 
from Parkinson's disease. Medicaid provides the McGraths peace of mind 
knowing Maura will receive the care that she needs and they aren't 
alone to fend for themselves, given the tough hand they have been 
dealt.
  Mr. Speaker, for Maura and everyone in my district, say ``no'' to 
TrumpCare.
  Mrs. BLACK. Mr. Speaker, I yield 2 minutes to the gentleman from 
Louisiana (Mr. Higgins).
  Mr. HIGGINS of Louisiana. Mr. Speaker, I rise unscripted and in 
passionate support of freedom. I have heard many statements with words 
like ``fact'' and details of the minutia of these plans. I will share 
with you a fact.
  Two hundred years ago, my ancestral forefather was born. He was a 
young, poor Irishman born into indentured servitude. He heard a whisper 
of a land born across the sea, a land where a man could own his own 
property, a land where a man could keep the toil of his labor. So he 
garnered his courage, he saved his money, and he booked passage on a 
cargo vessel converted to carry human beings. According to the letter 
unearthed by my sainted mother, his sleeping berth measured 2 by 2 by 
5.

  What could have driven my ancestral forefather--and yours, Mr. 
Speaker--indeed, all of America? What drove our ancestral forefathers 
to come to this land? Freedom. Freedom drove us, and it is freedom for 
which I stand.
  The Affordable Care Act, known as ObamaCare, is 8,000 pages--8,000 
pages--of regulation and taxation. There is not a man or a woman 
amongst us, from sea to shining sea, who believes this body can produce 
8,000 pages of freedom. The American Health Care Act is 124 pages of 
reasonable legislation based upon the best input of free market 
principles.
  A vote against the American Health Care Act is a vote against 
freedom. It is a vote against 124 pages of reasonable legislation, and 
it is a vote for 8,000 pages of ObamaCare.
  Mr. Speaker, I urge my colleagues to vote ``yes'' for the American 
Health Care Act.
  Mr. YARMUTH. Mr. Speaker, I remind my colleague that the gentleman's 
vote for this bill will result in 50,100 people from his congressional 
district in Louisiana losing health coverage and care.
  Mr. Speaker, I yield 1\1/2\ minutes to the gentlewoman from 
Washington (Ms. Jayapal), who is the distinguished vice ranking member 
of the Budget Committee.
  Ms. JAYAPAL. Mr. Speaker, I thank the distinguished gentleman for 
yielding and for his tremendous leadership.
  Mr. Speaker, this reckless Republican plan is a betrayal of the 
American people. How is it a betrayal?
  Callously stripping 24 million people of health care is a betrayal.
  Putting an age tax on people aged 50 to 64 who will pay up to $14,000 
more in annual premiums is a betrayal.
  Gutting essential benefits like maternity care, prescription drug 
coverage, emergency services, and fundamentally destroying protections 
for Americans with preexisting conditions is a betrayal.
  Slashing Medicaid by $880 billion and stripping the safety net for 
our seniors, our kids, and people with disabilities is a betrayal.
  The burden of all of this, Mr. Speaker, will fall on the States, who 
will have to come up with billions of dollars.
  Mr. Speaker, this bill is not about freedom or choice. This bill is a 
travesty, and the American people will pay the price.
  This is not a healthcare bill. The only people who benefit are 
millionaires, billionaires, and insurance companies, who will get $1 
trillion in tax benefits while working Americans pay more and get 
nothing.
  Mr. Speaker, this bill is pure greed, and real people will suffer and 
die from it. Vote ``no,'' and protect our care.
  Mrs. BLACK. Mr. Speaker, I yield myself such time as I may consume.
  Mr. Speaker, I want to recognize that our Members on the other side 
of the aisle are sharing some data on the coverage of per congressional 
district based on a study that was conducted by the Center for American 
Progress, which is a left-leaning organization to begin with. The 
Center for American Progress employs a flawed methodology for 
estimating this coverage. In

[[Page H2411]]

fact, their foundational numbers are actually based on CBO's coverage 
estimates, estimates that the CBO itself has established are not 
infallible.
  These coverage numbers only take into account plans that they 
consider comprehensive major medical policies. This is a term that is 
used in the very law that we are trying to dismantle today. These 
coverage estimates do not account for things that we have in our bill, 
such as HSA plans that allow purchase with tax credits, and many 
medical plans.
  So the AHCA increases freedom for Americans to purchase the kind of 
coverage that works for them, not the narrowly defined coverage that we 
see that the Federal Government likes.
  Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from California 
(Mr. McClintock), who is a member of our committee.
  Mr. McCLINTOCK. Mr. Speaker, I simply want to underscore what the 
chairwoman has already laid out.
  When my friend from Kentucky says that his constituents will lose 
coverage, he is basing it on two premises. He is ignoring the $90 
billion of additional funds that we freed up in the Budget Committee to 
assure that nobody will face sticker shock as we make this transition.
  Second, he assumes that the only reason that people buy insurance is 
if we force them to buy it. The reality is many are refusing to buy 
ObamaCare policies even when they are faced with these crushing tax 
policies. The AHCA replaces this heavyhanded and failing bureaucratic 
nightmare.
  Ultimately, we are going to be judged not on polls or fairy tales, 
but on whether the vast majority of Americans have a better experience 
with this new consumer-driven market than they had with the 
bureaucratized, one-size-fits-all ObamaCare system. That system has 
already been weighed in the balance and found wanting by the American 
people, and I am here to stake my reputation on the prediction that 
they will find better policies with better services at lower costs when 
they are restored the freedom to be consumers in a marketplace with a 
supportive tax structure that assures that these policies are within 
the financial reach of every American family.
  Mr. YARMUTH. Mr. Speaker, I remind my colleague that his vote for 
this bill will result in 38,200 people from his congressional district 
in California losing health coverage and care.
  Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from California 
(Mr. Carbajal), who is a distinguished member of the Budget Committee.
  Mr. CARBAJAL. Mr. Speaker, before I came to Congress, I worked in 
local government as a county supervisor. One of my proudest 
achievements during that time was working in a bipartisan way to create 
a program that reduced the rate of uninsured children in our county by 
over 90 percent--all before the Affordable Care Act was signed into 
law. Since the Affordable Care Act, I saw firsthand the direct and 
positive impact of this legislation over the past 7 years to 
communities and families across the central coast.
  The Affordable Care Act meant Sarah, from Lompoc, could open her 
small business and afford insurance coverage for her two children.
  It meant that Kathleen, in San Luis Obispo, who was diagnosed with 
ovarian and breast cancer, that her $500,000 medical bill was covered 
by her healthcare plan.
  It meant that Adrienne, from Buellton, now could afford to pay for 
her husband's nursing facility, as his debilitating disease prevents 
her from being able to physically care for him.
  Repealing legislation that has improved the quality of life not only 
for Sarah, Kathleen, and Adrienne, but for the over 20 million 
Americans who have gained health insurance under the Affordable Care 
Act, would be callous, cruel, and irresponsible.
  Instead of taking away health care from 24 million Americans, let's 
work together to create a more equitable, affordable, and accessible 
healthcare system for all.

                              {time}  1215

  Mrs. BLACK. Mr. Speaker, I yield 1 minute to the gentleman from South 
Carolina (Mr. Sanford).
  Mr. SANFORD. Mr. Speaker, I want to make clear that I agree with what 
every Republican speaker has said thus far on the need to repeal and 
replace the Affordable Care Act. I want to say how much I admire the 
Speaker and the leadership team, President Trump and his team, 
Chairwoman Black, and others on the Budget Committee for what they have 
brought to bear.
  My simple question is one of timing. What I tell my boys consistently 
is: If you don't know, you don't go.
  One of the things that I think we have to really look at in this bill 
is one of process. It does do a lot of good things, as has been pointed 
out by the Republican speakers, but it still leaves in place community 
rating. It leaves in place the architecture, I think, of a flawed bill 
that came with the Affordable Care Act.
  The question is: Can we build on top of that to do the very good 
things that are talked about in this bill, or do we take just a little 
bit more time to make certain that we have it right?
  I think that when you look at this notion of lowering premiums, look 
at it like rent control in New York. Rent control in New York has done 
a lot of good for some folks, but it has hurt a lot of others in the 
process.
  The question we fundamentally have to ask ourselves is: At this 
juncture, can we make the changes necessary?
  Mr. YARMUTH. Mr. Speaker, I mention to my colleague that his vote 
against this bill will result in 56,600 people from his congressional 
district in South Carolina losing health coverage and care.
  Mr. Speaker, I yield 1\3/4\ minutes to the gentlewoman from Texas 
(Ms. Jackson Lee).
  Ms. JACKSON LEE. Mr. Speaker, I thank the distinguished gentleman of 
the Budget Committee for his leadership.
  Our mothers and our doctors have warned us about poison pills. Well, 
let me say that, this morning, the Republicans are giving to the 
American people a poison meal that would affect my friend, the senior 
citizen, with $175 billion being taken away from Medicare; a poison 
meal that will affect a young child who is being seen by a doctor.
  The Children's Hospital Association, including the Texas Children's 
Hospital, has said to vote ``no'' on this bill because 30 million 
children will have no health insurance.
  This will impact working families making $31,000 a year. They will 
have to pay $4,000 more out of pocket. In 2026, under pay more for 
less, $52 million Americans will be uninsured.
  This poison meal is getting worse and worse.
  Then, in the dark of night, what did they do?
  They took away hospitalization. They took away pregnancy, maternity, 
and newborn care. They took away mental health and substance abuse 
care.
  Those States that are experiencing the opioid abuse and epidemic, 
what are they going to do?
  They have threatened community health centers. They are closing rural 
hospitals.
  What is this disaster of TrumpCare?
  It is injuring my good friend who is sitting there in the hospital 
room. It is injuring Anna Nunez. It is injuring small businesses who 
say that they can live better under the Affordable Care Act, and the 
youngster that is a junior in college who said she would not be alive 
had it not been for the Affordable Care Act.
  More than half of the American people--and it is growing--are against 
this bill done in the dark of night. It is the poison meal that is 
keeping those who need health insurance away from health insurance.
  I ask my colleagues to vote ``no.'' Don't feed the American people a 
poison meal.
  Mr. Speaker, as a member of the Budget Committee and the 
representative of a congressional district that has benefited 
enormously from the Affordable Care Act, I rise in strong and 
unyielding opposition to H.R. 1628, the so-called ``American Health 
Care Act,'' which more accurately should be called ``Trumpcare, the Pay 
More For Less Act.''
  Seven years ago yesterday, March 23, 2010, President Barack Obama 
signed into law the landmark Affordable Care Act passed by the 
Democratic controlled 111th Congress.
  Seven years later, the verdict is in on the Affordable Care Act; the 
American people have judged it a success and are adamantly opposed to 
any effort to repeal a law that has brought to more than 20 million 
Americans the peace of mind and security that comes with

[[Page H2412]]

knowing they have access to affordable, high quality health care.
  Before the passage of the Affordable Care Act, 17.1 of Americans 
lacked health insurance; today nearly nine of ten (89.1%) are insured, 
which is the highest rate since Gallup began tracking insurance 
coverage in 2008.
  Because of the Affordable Healthcare Act:
  1. insurance companies are banned from discriminating against anyone, 
including 17 million children, with a preexisting condition, or 
charging higher rates based on gender or health status;
  2. 6.6 million young-adults up to age 26 can stay on their parents' 
health insurance plans;
  3. 100 million Americans no longer have annual or life-time limits on 
healthcare coverage;
  4. 6.3 million seniors in the ``donut hole'' have saved $6.1 billion 
on their prescription drugs;
  5. 3.2 million seniors now get free annual wellness visits under 
Medicare, and
  6. 360,000 Small Businesses are using the Health Care Tax Credit to 
help them provide health insurance to their workers;
  7. Pregnancy is no longer a pre-existing condition and women can no 
longer be charged a higher rate just because they are women.
  We are becoming a nation of equals when it comes to access to 
affordable healthcare insurance.
  The President and congressional Republicans call this enviable record 
of success a ``disaster.''
  The American people do not agree and that is why they reject 
overwhelmingly (56%-17%) this Republican attempt to repeal the 
Affordable Care Act according to the latest Quinnipiac poll.
  Americans know a disaster when they see one and they see one in the 
making: it is called ``Trumpcare,'' masquerading as the ``American 
Health Care Act,'' which will force Americans to ``pay more for less.''
  And they are right to be alarmed at what they see.
  This ``Pay-More-For-Less'' bill is a massive $900 billion tax cut for 
the wealthy, paid for on the backs of America's seniors, the 
vulnerable, the poor, and working class households.
  This ``Robin Hood in reverse'' bill is unprecedented and breathtaking 
in its audacity--no bill ever tried to give so much to the rich while 
taking so much from the poor and working class.
  Trumpcare represents the largest transfer of wealth from the bottom 
99% to the top 1% in American history.
  This callous Republican scheme gives gigantic tax cuts to the rich, 
and pays for it by taking insurance away from 24 million people, 
leaving 52 million uninsured, and raising costs for the poor and middle 
class.
  In addition, Republicans are giving the pharmaceutical industry a big 
tax repeal, worth nearly $25 billion over a decade without demanding in 
return any reduction in the cost of prescription and brand-name drugs.
  To paraphrase Winston Churchill, of this bill, it can truly be said 
that ``never has so much been taken from so many to benefit so few.''
  The Pay-More-For-Less plan destroys the Medicaid program under the 
cover of repealing the Affordable Care Act Medicaid expansion.
  CBO estimates 14 million Americans will lose Medicaid coverage by 
2026 under the Republican plan.
  In addition to terminating the ACA Medicaid expansion, the bill 
converts Medicaid to a per-capita cap that is not guaranteed to keep 
pace with health costs starting in 2020.
  The combined effect of these policies is to slash $880 billion in 
federal Medicaid funding over the next decade.
  The cuts get deeper with each passing year, reaching 25% of Medicaid 
spending in 2026.
  These steep cuts will force states to drop people from Medicaid 
entirely or ration care for those who most need access to comprehensive 
coverage.
  The Pay-More-For-Less plan undermines the health care safety net for 
vulnerable populations.
  Currently, Medicaid provides coverage to more than 70 million 
Americans, including children, pregnant women, seniors in Medicare, 
people who are too disabled to work, and parents struggling to get by 
on poverty-level wages.
  In addition to doctor and hospital visits, Medicaid covers long-term 
services like nursing homes and home and community-based services that 
allow people with chronic health conditions and disabilities to live 
independently.
  To date, 31 states and D.C. have expanded Medicaid eligibility to 
low-income adults, which, when combined with the ACA's other coverage 
provisions, has helped to reduce the nation's uninsured rate to the 
lowest in history.
  Trumpcare throws 24 million Americans off their health insurance by 
2026 according to the Congressional Budget Office.
  Low-income people will be hit especially hard because 14 million 
people will lose access to Medicaid by 2026 according to CBO.
  Trumpcare massively shifts who gets insured in the nongroup market.
  According to CBO, ``fewer lower-income people would obtain coverage 
through the nongroup market under the legislation than current law,'' 
and, ``a larger share of enrollees in the nongroup market would be 
younger people and a smaller share would be older people.''
  The projected 10% reduction in premiums is not the result of better 
care or efficiency--it is in large part the result of higher-cost and 
older people being pushed out of a market that is also selling plans 
that provide less financial protection.
  People with low incomes suffer the greatest losses in coverage.
  CBO projects the uninsured rate for people in their 30s and 40s with 
incomes below 200% of poverty will reach 38% in 2026 under this bill, 
nearly twice the rate projected under current law.
  Among people aged 50-64, CBO projects 30% of those with incomes below 
200% of poverty will be uninsured in 2026.
  Under current law, CBO projects the uninsured rate would only be 12 
percent.
  Being uninsured is not about ``freedom.''
  Speaker Ryan has argued that people will happily forgo insurance 
coverage because this bill gives them that ``freedom.''
  The argument makes as much sense as the foolish claim that slaves 
came to America as ``immigrants'' seeking a better life.
  The freedom to be uninsured is no freedom at all to people in their 
50s and 60s with modest incomes who simply cannot afford to pay 
thousands of dollars toward premiums.
  They do not really have a choice.
  The claim of our Republican friends that Trumpcare provides more 
freedom to all Americans calls to mind the words of Anatole France:
  ``The law, in its majestic equality, forbids the rich as well as the 
poor to sleep under bridges, to beg in the streets, and to steal bread 
from the market.''
  Trumpcare raises costs for Americans nearing retirement, essentially 
imposing an ``Age Tax.''
  The bill allows insurance companies to charge older enrollees higher 
premiums than allowed under current law, while reducing the size of 
premium tax credits provided.
  Again, these changes hit low-income older persons the hardest.
  A 64-year-old with an income of $26,500 buying coverage in the 
individual market will pay $12,900 more toward their premiums in 2026, 
on average.
  Trumpcare raises costs for individuals and families with modest 
incomes, particularly older Americans.
  A recent analysis found that in 2020, individuals with incomes of 
about $31,000 would pay on average $4,000 more out of pocket for health 
care--which is like getting a 13% pay cut.
  And the older you are, the worse it gets.
  An analysis by the Urban Institute estimates that for Americans in 
their 50s and 60s, the tax credits alone would only be sufficient to 
buy plans with major holes in them, such as a $30,000 deductible for 
family coverage and no coverage at all of brand-name drugs or many 
therapy services.
  Another reason I oppose the Trumpcare bill before us is because its 
draconian cuts in Medicaid funding and phase-out of Medicaid expansion 
put community health centers at risk.
  Community health centers are consumer-driven and patient-centered 
organizations that serve as a comprehensive and cost effective primary 
health care option for America's most underserved communities.
  Community health centers serve as the health care home for more than 
25 million patients in nearly 10,000 communities across the country.
  Across the country, 550 new clinics have opened to receive 5 million 
new patients since 2009.
  Community health centers serve everyone regardless of ability to pay 
or insurance status:
  1. 71% of health center patients have incomes at or below 100% of 
poverty and 92% have incomes less than 200% of poverty;
  2. 49% of health center patients are on Medicaid; and
  3. 24% are uninsured;
  4. Community health centers annually serve on average 1.2 million 
homeless patients and more than 300,000 veterans.
  Community health centers reduce health care costs and produce 
savings--on average, health centers save 24% per Medicaid patient when 
compared to other providers.
  Community health centers integrate critical medical and social 
services such as oral health, mental health, substance abuse, case 
management, and translation, under one roof.

[[Page H2413]]

  Community health centers employ nearly 190,000 people and generate 
over $45 billion in total economic activity in some of the nation's 
most distressed communities.
  Community health centers serve on the front lines of public health 
crises such as the Zika virus and the opioid epidemic.
  Mr. Speaker, community health centers are on the front lines of every 
major health crisis our country faces, from providing access to care 
(and employment) to veterans to addressing the opioid epidemic to 
responding to public health threats like the Zika virus.
  We should be providing more support and funding to community health 
centers, not making it more difficult for them to serve the communities 
that desperately need them by slashing Medicaid funding.
  Trumpcare Republican plan leaves rural Americans worse off.
  Mr. Speaker, health insurance has historically been more expensive in 
rural areas because services cost more and it is hard to have a stable 
individual market with a small population.
  Under the Affordable Care Act, premium subsidies are tied to local 
costs, which helps keeps premium costs down.
  But they are not under the Republican plan.
  So, under the Republican plan residents in rural areas, who tend to 
be older and poorer, will pay much more and get much less health 
insurance.
  At the end of the day, Mr. Speaker, the powerful and compelling 
reasons to reject Trumpcare lies in the real world experiences of the 
American people.
  Let me briefly share with you the positive, life affirming difference 
made by the Affordable Care Act in the lives of just three of the 
millions of Americans it has helped.
  Joan Fanwick: ``If Obamacare is repealed, I don't know if I'll live 
to see the next President''
  ``After nearly a decade of mysterious health scares, I was diagnosed 
with an autoimmune disorder called Sjogren's Syndrome last year, when I 
was a junior at Temple University.
  ``It's a chronic illness with no known cause or cure, and without 
close medical surveillance and care, it can lead to life-threatening 
complications (like the blood infections I frequently experience).
  ``For me, having this disorder means waking up every morning and 
taking 10 different medications.
  ``It also means a nurse visiting my apartment every Saturday to 
insert a needle into the port in my chest, so I can give myself IV 
fluids throughout the week.
  ``Without insurance, my medical expenses would cost me about $1,000 
per week--more than $50,000 per year. And that doesn't even include 
hospitalizations.
  ``My medical bills aren't cheap under Obamacare, but I can afford 
them.
  ``Under Obamacare, insurance companies aren't allowed to cut you off 
when your costs climb so right now, the most I personally have to pay 
out of pocket is $1,000 per year.''
  Brian Norgaard: ``I am a small business owner and leadership trainer 
who Obamacare has helped tremendously.''
  Brian Norgaard, a Dallas, Texas resident, called my office to express 
his opposition to Trumpcare and to offer share how the Affordable Care 
Act has helped small business owners like himself:
  ``I am a small business owner and leadership trainer who Obamacare 
has helped tremendously.
  ``My wife and I both own small businesses in the Dallas, Texas area 
and as a result of the huge savings we received after paying lower 
[healthcare] premiums under Obamacare, we were able to reinvest those 
saving into both of our businesses and the community.
  ``And the healthcare we received was quality, at that.''
  Ashley Walton: ``For cancer survivors, we literally live and die by 
insurance''
  Ashley Walton was 25 when a mole on her back turned out to be 
melanoma.
  She had it removed, but three years later she discovered a lump in 
her abdomen.
  She was then unemployed and uninsured, and so she put off going to a 
doctor.
  She tried to buy health insurance. Every company rejected her.
  Ashley eventually became eligible for California's Medicaid program, 
which had been expanded under the Affordable Care Act.
  The 32-year-old Oakland resident credits her survival to the ACA.
  Without it, ``I would likely be dead, and my family would likely be 
bankrupt from trying to save me.''
  Before any of our Republican colleagues supporting this bill cast 
their vote, I urge them to reflect on the testimony of Joan, Brian, and 
Ashley, and to on this question posed by a constituent to Sen. Cotton 
of Arkansas at a recent town hall:
  ``I've got a husband dying and we can't afford--let me tell you 
something.
  ``If you can get us better coverage than this [Obamacare], go for it.
  ``Let me tell you what we have, plus a lot of benefits that we need.
  ``We have $29 per month for my husband. Can you beat that? Can you?
  With all the congestive heart failures, and open heart surgeries, 
we're trying. $29 per month. And he's a hard worker.
  $39 for me.''
  I urge all Members to reject Trumpcare, one of the most monstrously 
cruel and morally bankrupt legislative proposals ever to be considered 
in this chamber.
  To paraphrase a famous former reality television personality, 
``believe me, Trumpcare is a disaster.''
  We should reject it and keep instead ``something terrific'' and that 
is the Affordable Care Act, regarded lovingly by millions of Americans 
as ``Obamacare.''

                                                   March 24, 2017.
     Re Changes to the Affordable Healthcare Act.

     The President of the United States of America,
     The White House,
     Washington, DC.
       Greetings Mr. President: Today is a very crucial and 
     important day for the residents of the City of Houston's 
     District D, where I serve as the elected City Council Member, 
     which also falls under Congressional Districts 18 and 7. As a 
     local elected official whose mother is on a fixed income, 
     this will not only impact her but many other senior citizens 
     who I represent.
       In the news, we see how the Affordable Healthcare Act is 
     proposed to be changed. Under the new revisions to the 
     healthcare bill, which is called The American Health Care 
     Act, about $337 Billion will be cut from the current plan 
     over a 10 year period causing 24 million Americans, including 
     Democrats, Republicans, Independents, poor and the middle 
     class, to lose their healthcare. This proposed health care 
     bill is receiving criticism from the health care providers, 
     some conservatives and a united Democratic Party. The 
     Congressional Budget Office even showed how this current 
     proposed plan will negatively impact everyone. What is most 
     concerning to me in regards to this program is the impact 
     that it will have on our senior citizens.
       52% of my District is made up of Senior Citizens who are on 
     fixed incomes. These senior's will have to pay more for their 
     health care under this proposed American Health Care Act. In 
     no way is this acceptable. I am an advocate for my seniors 
     and I refuse to quietly sit back while this is being 
     considered.
       I have encouraged everyone to reach out to their Members of 
     Congress to let them know that this isn't something that we 
     stand for and to work on their behalf to vote this item down 
     today.
           Sincerely,

                                               Dwight Boykins,

                                             Houston City Counsel,
                                                       District D.

  Mrs. BLACK. Mr. Speaker, I yield 2 minutes to the gentleman from 
Wisconsin (Mr. Grothman), who is also a member of the Budget Committee.
  Mr. GROTHMAN. Mr. Speaker, I would encourage my colleagues to vote 
for the bill. The reason I ask you to vote for the bill is kind of like 
the reverse: What is going to happen if this bill fails?
  If this bill fails, you won't be able to have the huge increase in 
funding in HSAs, a free-market, patient-centered tax provision which is 
going to help many people and particularly allow flexibility for older 
married couples.
  If this bill doesn't pass, we are going to continue to levy fines on 
young people who don't want health insurance, as so many people have 
not had when they are young. We will continue to levy fines on small 
business that can't afford health insurance.
  If this bill fails to pass, we are not going to allow States to put 
work requirements on Medicaid. Quite frankly, Medicaid, in many ways, 
is a more generous policy than the one that people who do work are able 
to afford through their insurers.

[[Page H2414]]

  If this bill doesn't pass, we won't be able to stop the bleeding on 
Medicaid funding. We are approaching a $20 trillion debt. Of course, 
the bulk of that spiraling debt is caused by mandatory spending, of 
which Medicaid is one of the worst parts.
  Finally, for the first time in years, we are passing a law that will 
make a significant dent in that mandatory spending.
  If this bill isn't passed, we prevent putting a provision in here 
requiring documentation of citizenship for Medicaid. Right now, we are 
becoming the healthcare provider for the world. We cannot afford to 
become the healthcare provider of the world.
  Under this bill, we are providing funds, seed money for high-risk 
pools for States, which will hold down insurance costs, which is the 
underlying problem we have here.
  If this bill doesn't pass, we continue to fund abortion providers. I 
think this is the best bill in decades for those of us who wish we 
would stop funding these organizations.
  We are providing assistance for people who can't get insurance 
through their employer. It is high time the Tax Code provided equality 
for people who get insurance from their employer and those who don't.
  Finally, if we don't pass this bill, we don't end ObamaCare.
  The SPEAKER pro tempore. The time of the gentleman has expired.
  Mrs. BLACK. Mr. Speaker, I yield an additional 30 seconds to the 
gentleman.
  Mr. GROTHMAN. Already a third of the counties only have one provider. 
If we don't pass this bill now, we are going to go into the next year 
and we are going find a lot of people who think they have ObamaCare but 
have nothing because there will be no providers left.
  We have got to step in to save those people and provide insurance in 
those counties in which ObamaCare will leave no insurance companies 
remaining.
  Mr. YARMUTH. Mr. Speaker, I remind my colleague that his vote for 
this bill will result in 44,600 people from his congressional district 
in Wisconsin losing health coverage and care.
  Mr. Speaker, I yield 2 minutes to the gentlewoman from Illinois (Ms. 
Schakowsky), a distinguished member of the Budget Committee and the 
Energy and Commerce Committee.
  Ms. SCHAKOWSKY. Mr. Speaker, I sincerely ask my Republican 
colleagues: Did you really come here to take health care away from 24 
million people?
  Over 40,000 people in my district will lose their coverage.
  Did you come to Congress to make insurance more expensive for my 
constituent, Mary, who has a preexisting condition and now pays half of 
what she used to pay for insurance because of the tax credits she got 
from ObamaCare?
  Did you come to Congress to impose a crippling age tax on Americans 
50 to 60 years old?
  Your bill would increase their premiums an average of $8,000 a year. 
According to the Congressional Budget Office, within 10 years, nearly 
30 percent of those 50-to 64-year-olds would be without any insurance.
  Did you really come to Congress to take nursing home and home care 
away from the elderly and the disabled?
  Did you get elected in order to take health care from mothers?
  Your bill would kick them off of Medicaid if they don't find a job 60 
days after they give birth.
  We have heard over and over that patients need choices and should be 
empowered to choose the care that they want. But, apparently, that 
doesn't apply to women. The bill would block millions of women from 
choosing Planned Parenthood, a trusted healthcare provider to 2.5 
million patients every year.
  The American people are not clamoring for you to repeal ObamaCare. 
Only 17 percent of Americans say that you should vote to repeal 
ObamaCare. The average American overwhelmingly wants you to vote 
``no.''
  Mrs. BLACK. Mr. Speaker, I yield 2 minutes to the gentleman from 
Kansas (Mr. Marshall), who is a physician.
  Mr. MARSHALL. Mr. Speaker, Kansas voters sent me to fix health care. 
Doing nothing is not an option. I cannot sit here idly while the ACA 
destroys and bankrupts America's healthcare system.
  This bill eliminates nearly a trillion dollars of taxes. This bill 
eliminates funding for Planned Parenthood. This bill will save many 
hospitals in Kansas from closing by increasing funding for Medicare 
patients. This bill allots $100 billion for high-risk pools. This bill 
specifies another $15 billion specifically for maternity coverage, 
which is near and dear to my heart; newborn care; mental health care; 
and substance abuse disorders.
  Mr. Speaker, this is the best bill that we can get through this 
process. I am excited to be part of it. This is the first chapter of a 
new book, with many more chapters to come. We will fix health care.
  Mr. YARMUTH. Mr. Speaker, I remind my colleague that his vote for 
this bill will result in 50,000 people from his congressional district 
in Kansas losing health coverage and care.
  Mr. Speaker, I yield myself 2 minutes.
  Mr. Speaker, in concluding the presentation from the Budget 
Committee, I just have to say that the bill we are considering today is 
a mess. It is not a healthcare bill at all.
  This bill is driven by a desire to cut taxes for the wealthiest 
Americans and many wealthy corporations by nearly $1 trillion in all. 
It is paid for by making health care unaffordable for millions of 
people.
  This is irresponsible. It is not what the American people want, it is 
not what they deserve, and it is certainly not what they can afford.
  We are not the only ones opposing this legislation. It is opposed by 
an amazing array of American organizations and individuals, including 
the American Medical Association, the American Hospital Association, 
the American Nurses Association, the National Rural Health Association, 
AARP, the National Disability Rights Network, the American Diabetes 
Association, American Cancer Society, and Easterseals, virtually every 
healthcare and consumer advocacy group, Governors from both sides of 
the aisle, and a growing list of our Republican colleagues.
  Mr. Speaker, I thank the Budget Committee staff for the incredible 
job they have done throughout this process.
  Mr. Speaker, I reserve the balance of my time, and I ask unanimous 
consent that the gentleman from New Jersey (Mr. Pallone), chairman of 
the Energy and Commerce Committee, control the balance of my time.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from Kentucky?
  There was no objection.
  Mrs. BLACK. Mr. Speaker, I yield myself such time as I may consume.
  Mr. Speaker, I want to remind my fellow colleagues that, currently, 
when we look at the access to care for people, one-third of our 
counties only have one provider; two-thirds of our counties only have 
two providers. In my State of Tennessee, there are 14 counties where 
they will have no insurance provider on the marketplace. So when we 
talk about people losing their insurance, they are losing their 
insurance by not having access to even purchase the insurance.
  One of my former colleagues, the gentleman from Minnesota, asked: 
What are my colleagues on the other side of the aisle trying to 
preserve?
  I want to point to this chart here to ask that question, because 
these are the broken promises of ObamaCare.
  Why are you trying to preserve something where they say premiums will 
decrease by $2,500, and we see the average family premiums have soared 
by $4,300, making insurance unaffordable for many families?
  Another broken promise: the cost of health care will go down.
  We see some deductibles that have gone up as much as 60 percent. In 
my own State, they have gone up by 63 percent, making coverage 
unaffordable.
  You can keep your doctor--70 percent of the plans consist of narrow 
networks, which means they cannot keep their doctor. I cannot tell you 
the number of people who have called me because their doctor was not on 
their inept plan.
  Finally, ``middle class Americans won't see a tax increase.'' This 
was a promise by former President Obama. ObamaCare penalties were put 
in place, so people are receiving a tax penalty.
  These are the broken promises that the other side of the aisle wants 
to continue to protect. As opposed to that, we

[[Page H2415]]

want a system that is going to be open with patient care and give 
affordability so people can get the services that they want with a cost 
that they can afford.
  I also thank the Budget Committee for the work that they have done, 
and all the staff that have worked endless hours to make it possible 
for this to be here on the floor today.
  Mr. Speaker, I yield 30 minutes to the gentleman from Oregon (Mr. 
Walden), and I ask unanimous consent that he may control that time.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentlewoman from Tennessee?
  There was no objection.
  Mr. WALDEN. Mr. Speaker, I yield myself such time as I may consume.
  After 7 years, we have heard the stories of our constituents, 
patients, friends, and family who have suffered under ObamaCare. We 
have heard from those who have benefited in some respects.
  I think of the struggles of constituents like Indra from Bend, 
Oregon. She lost her private insurance and her preferred doctor. When 
she went to look for a new plan under ObamaCare, she found the plans 
were too expensive, and she went without insurance for almost 2 years. 
See, her story should not be lost in this debate either.

                              {time}  1230

  Then there is April. Last fall, she found out her insurer would not 
be offering her plan this year. The most comparable plan available 
would raise her monthly premium by $564 per month, bringing her total 
monthly premium to $1,503.
  You see, there is a whole other group of Americans out there who are 
suffering these effects of ObamaCare. The American Health Care Act 
represents a better way for patients like Indra and April all across 
our country. Our plan will rescue and revitalize the market and lower 
costs and increase flexibility for patients to choose. They will have 
more choices for health care and keep a health insurance plan that 
works for them and for their family.
  This legislation creates the Patient and State Stability Fund. Now, 
this is an innovative approach to give States the financing and 
flexibility to repair the damage done to the insurance markets by 
ObamaCare and meet the unique needs of their citizens. More 
importantly, we provide an additional $15 billion, Mr. Speaker, to 
States devoted for maternity coverage. We heard from people who said we 
need to do more in this area: newborn care, mental health, and 
substance disorders.
  We are also taking action to strengthen Medicaid. We want to put 
Medicaid on a sustainable path so it can better care for those it was 
intended to serve, a path through this per capita program for States 
that, frankly, was at one time embraced by Democrats, including 
President Clinton.
  The most vulnerable in our communities need this help. It represents 
the most substantive reform to the Medicaid program since its creation 
and will restore power to our States and local communities and 
governments where they can make better decisions than a one-size-fits-
all here in Washington. We want to give our States more control in how 
they manage these people that they are closest to.
  In closing, I want to thank our colleagues and the President of the 
United States and the Vice President and Secretary Price. They have 
worked day in and day out, tirelessly, without hesitation, to help get 
to the best policy possible here and to work and listen to our 
colleagues, as we have all done, to craft the best bill we can, given 
the constraints under which we must operate.
  The end result highlights the diverse ideas of our Conference that 
come from the American people and the determination that we share to 
save this market and make it work again.
  Remember, we are talking about a narrow slice of the insurance 
market, that driven by ObamaCare, that, last year, there were 225 
counties in America where, if you were looking for insurance on that 
exchange, you had one option. This year, it is 1,022 counties. That is 
one out of every three in America. And that was before Humana pulled 
out and other companies said this market is about gone.
  We need to fix this market. That is what this legislation seeks to 
do.
  Mr. Speaker, I want to thank our terrific staff that has worked day 
and night to get us to this point. We know there is a lot more work to 
do. This should not be taken in isolation as the only healthcare reform 
on our list. We are going to go after the cost drivers. We are going to 
go after prescription costs. We are going to go after hospital costs.
  Wherever it is in the health system, if you have nothing to hide, you 
won't have to fear our investigations. But we are going to get costs 
down. We are going to get costs down.
  The American Health Care Act is just the first step in our mission to 
rescue the American people from the failures of the underlying law. We 
know they are there. We are going to fix this. We are committed to it.
  Mr. Speaker, I reserve the balance of my time.
  Mr. PALLONE. Mr. Speaker, I yield myself such time as I may consume.
  Mr. Speaker, I remind my colleague, my chairman, Greg Walden, that 
his vote for this bill will result in 64,300 people from his 
congressional district in Oregon losing health coverage and care.
  Mr. Speaker, President Trump and congressional Republicans are not 
leveling with the American people when they say no one will be worse 
off under this repeal bill. TrumpCare dismantles the health and 
economic security that millions of hardworking Americans have gained 
over the last 7 years, and it should be defeated.
  There is a reason this bill was hatched up in the back rooms only to 
be finalized last night, and that is because congressional Republicans 
did not want the American people to see what was in it.
  TrumpCare provides less coverage, fewer protections, and higher 
costs.
  TrumpCare is Robin Hood in reverse, taking benefits and financial 
assistance from hardworking, middle class Americans and our most 
vulnerable in order to give tax breaks to the wealthiest and the 
corporations.
  TrumpCare cuts a combined $1 trillion from Medicare and Medicaid. 
These cuts are devastating, Mr. Speaker.
  TrumpCare will ration care for the 76 million Americans who rely on 
Medicaid, including seniors with long-term care needs, Americans with 
disabilities, pregnant women, and vulnerable children.
  I fear for seniors, Mr. Speaker, those in nursing homes. When States 
get less money, what will they do? They will give less money to nursing 
homes. We will go back to the days that I remember in New Jersey when 
nursing homes were terrible places, where there weren't enough nurses, 
where there were fires because of lack of maintenance of the nursing 
home.
  Working families are going to pay more for less. They will see their 
premiums and deductibles skyrocket. My GOP colleagues talk about high 
deductibles and copays. Well, you ain't seen nothing yet.
  You are going to see that this repeal repeals the limits on 
deductibles and copays that exist under the current law. Out-of-pocket 
costs are going to go through the roof. The deductibles will go even 
higher. The copays will go even higher. The out-of-pocket costs will go 
even higher.

  And the bottom line is Americans between the ages of 50 and 64 will 
pay an age tax and be forced to pay premiums five times higher than 
what younger people pay for their coverage.
  I have heard my colleagues on the other side say, well, that is only 
fair. Well, I don't think it is fair that seniors should have to pay a 
lot more, that those between 50 and 64 should have to pay a lot more.
  Also, TrumpCare leaves the sickest and vulnerable Americans at the 
mercy of insurance companies, allowing them to charge a 30 percent 
penalty or sick tax to those who are unable to maintain continuous 
coverage. So if you fail to pay your insurance for a month and then you 
want to get it again, even if you have a preexisting condition, which 
is often the case, you are going to pay a 30 percent penalty, or sick 
tax. I don't think that is very fair.
  Last night, in order to garner votes from the extreme right in their 
party, House Republicans added a provision that eliminates protections 
for essential health benefits. Now, maybe people don't understand that, 
but let me explain it.

[[Page H2416]]

  The ACA ensured that, when a consumer purchased health insurance on 
the individual market or gained coverage through Medicaid expansion, 
their plan would cover 10 critical, essential benefits.
  TrumpCare eliminates this guarantee, meaning that unscrupulous 
insurance companies can sell skeletal plans, junk insurance, without 
benefits for hospitalization, maternity care, mental health, drug 
treatment services, and Americans won't even know what they are 
getting. They won't realize that they have worthless insurance until 
they get sick and it is too late.
  The bottom line is this bill should be defeated for so many reasons 
because so many more people will not have health insurance, because 
their costs are going to go up, and because they won't even know what 
insurance they are buying. We are going go to back to the old days of 
the Wild West when insurance companies could sell whatever junk 
insurance they want and the public won't even know what they are 
getting. It is a disaster for the American people.
  I urge my colleagues to vote ``no,'' and I reserve the balance of my 
time.
  Mr. WALDEN. Mr. Speaker, I yield myself 20 seconds.
  The irony of that argument is it was just a year or so ago that every 
Member of this House who was here at the time and the Senate, by a 
unanimous vote, agreed to waive the essential benefits he just listed 
off for the employment market between 51 and 100--and, by the way, 
those essential benefits don't apply to the large group market--so this 
has already been done.
  I yield 1\1/2\ minutes to the gentleman from Texas (Mr. Barton), the 
vice chairman of the full committee.
  Mr. BARTON. Mr. Speaker, I supported this bill when it came out of 
the Energy and Commerce Committee 2 or 3 weeks ago, and I want to thank 
Chairman Walden for his excellent leadership.
  As he knows, I had some concerns about the bill at the time. I didn't 
think it addressed all the problems that we needed to address.
  At the start of this week, I was a ``no'' vote--a friendly ``no'' 
vote, but I was a ``no'' vote. Our Republican leadership in the House 
and the President and his senior advisers continued to involve 
themselves in constructive discussions with people like myself. 
Yesterday they agreed to put back in the repeal of the essential health 
benefits provision, and that is a big win for conservative values, so I 
am now a ``yes'' vote.
  My friends on the left seem to think the only way to get a benefit is 
to have the Federal Government mandate it and then have the Federal 
Government pay for it. I am here to tell you, Mr. Speaker, that markets 
work. If we create a healthcare market where people can choose their 
insurance that fits their needs, there will be plans that provide for 
every so-called essential health benefit. But there will also be plans 
that provide for specific markets of young people without children or 
elderly couples or whatever it is.
  Mr. Speaker, markets work, and you don't have to mandate benefits for 
those markets to work.
  The SPEAKER pro tempore. The time of the gentleman has expired.
  Mr. WALDEN. Mr. Speaker, I yield an additional 15 seconds to the 
gentleman from Texas.
  Mr. BARTON. Mr. Speaker, we always want to score a touchdown. 
Sometimes we take a field goal. What we don't want to do today is take 
a safety.
  Vote for this bill. Let's send it to the other body and continue to 
work to improve it. It is a good bill. Please vote ``yes.''
  Mr. PALLONE. Mr. Speaker, I remind my colleague that, in Mr. Barton's 
case, his vote for this bill will result in 64,900 people from his 
congressional district in Texas losing health coverage and care.
  I yield 2 minutes to the gentlewoman from California (Ms. Eshoo).
  Ms. ESHOO. Mr. Speaker, I thank the gentleman for yielding me time.
  Mr. Speaker, the American people are very smart. They listen up. They 
kind of knit their eyebrows together. They listen to the debate. They 
want the facts, and then they make up their mind. What our colleagues 
on the other side of the aisle have brought forward today is a disaster 
for the American people, and the American people know it.
  You have 17 percent of the American people that are for your plan, 
and the reason why? They know there are going to be higher costs. 
Families are going to have to pay more and get less--pay more for their 
premiums, more for their deductibles, and more in their out-of-pocket 
costs.
  You are taking health care away from 24 million Americans. That is 
more than the entire population of Australia. Who comes to Congress to 
hurt people?
  The promise of the Affordable Care Act was no one--no one ever 
again--will be able to take away your insurance the way the insurance 
companies did 7-plus years ago. Now it is only the Republican Party 
that can take away Americans' insurance.
  There isn't one developed country in the world that has your plan. It 
is a combination of all kinds of things to get votes.
  What free markets? What are you talking about? There is hypocrisy 
here because you all have the Affordable Care Act insurance. Every 
single Member of Congress does. So I guess it is good enough for you 
but it is not good enough for your constituents.
  This is a matter of life and death. You are playing with people's 
lives. It is a profound issue. This doesn't deserve one vote in the 
House of Representatives. Vote it down.
  The SPEAKER pro tempore. The Chair would remind all Members to direct 
their remarks to the Chair.
  Mr. WALDEN. Mr. Speaker, I yield myself 10 seconds before I yield to 
the gentleman from Michigan.
  I would just suggest that the American people are very smart. 
Unfortunately, under ObamaCare, 19.2 million Americans said: I am not 
going to buy ObamaCare. I am going to pay a penalty to the IRS instead.
  You see, we are trying to fix it so they will want to buy it.
  I yield 2 minutes to the gentleman from Michigan (Mr. Upton).
  Mr. UPTON. Mr. Speaker, you know, there is an old Upton family quote 
that my grandfather would always say: Was you always perfect? No, none 
of us are.
  And you know what? This is not a perfect bill. That is for sure. But 
ObamaCare is broken. One out of three counties has only one provider, 
and it looks like it is going to get worse as other major insurance 
companies are on the verge of pulling the plug.
  Nearly two dozen of the nonprofit CO-OPS have already gone belly up. 
In my home State, folks saw their premiums increase by nearly 17 
percent. Some States have had premium increases of more than 100 
percent. Most had double-digit increases, many over 20 percent, and 
some forecast 40 to 50 percent increases come fall if nothing happens.
  The calls on both sides of the aisle have often used the R word--on 
this side, ``replace''; on your side, the Democratic side, ``repair.'' 
Let's both agree. The status quo is not acceptable. But this, this 
bill, is the only train leaving the station. Is it going to improve if 
it gets to the Senate? Of course it will. We should all work for that 
goal.
  For me, I worked with Medicaid expansion States like Michigan 
providing a reasonable transition until 2020 and then grandfathering 
all those folks until they are off. Some of my colleagues called to end 
Medicaid expansion even this year. They want total repeal.

                              {time}  1245

  What would total repeal mean? Total repeal would mean taking away the 
ability of HHS to provide flexibility to the States to administer this 
critical program. It would mean taking away insurance for young kids on 
their parents' policies. It would reinstall a cap on insurance. And, 
yes, it would allow insurance companies to discriminate against those 
with preexisting illnesses.
  This bill still allows all of those important protections to stay in 
place. A number of us will continue to work with HHS to provide even 
more flexibility to States like Michigan. This has to be a key 
component of moving forward.
  At the end of the day, I would like to think that we could work 
together on a bipartisan basis. High premiums and a lack of access 
impact us all. Let's work together. You can't get to second base unless 
you get to first.

[[Page H2417]]

  

  Mr. PALLONE. Mr. Speaker, I remind my colleague from Michigan that 
his vote for this bill will result in 43,500 people from his 
congressional district in Michigan losing health coverage and care.
  Mr. Speaker, I yield 1 minute to the gentleman from New York (Mr. 
Engel).
  Mr. ENGEL. Mr. Speaker, when people look at these bills, they want to 
know what they are going to pay. What this bill does is simple--you pay 
more and you get less. That is the bottom line--pay more and get less.
  The President promised better health care for more people at a lesser 
cost. But my Republican colleagues can no longer claim with any 
credibility that their plan achieves these goals.
  Twenty-four million people will lose coverage. People 50 to 64 will 
be hit with an age tax and pay premiums five times higher than 
everybody else. Deductibles will go up. And protections that make sure 
insurance companies offer minimum value will be thrown out.
  Again, the Republican bill, TrumpCare--pay more, get less--but it 
gives billionaires a tax break. That is really important; isn't it? 
With the Affordable Care Act, we set out to give Americans more 
affordable, higher quality health care.
  Is the law perfect? No. We should be working together to tweak the 
law. We should be working together to improve the law, not putting in a 
clunker like this bill, which will roll back the time on people's 
coverage. Roll back the time, give people less coverage, and let them 
pay more. That is not what the American people want. I urge my 
colleagues to vote ``no.''
  Mr. WALDEN. Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from 
Mississippi (Mr. Harper), the chairman of the House Administration 
Committee, and a valuable member of the Energy and Commerce Committee.
  Mr. HARPER. Mr. Speaker, ObamaCare has failed. Contrary to what was 
promised, premiums have gone up and there are fewer health insurance 
options. This bill addresses a crisis that before now had no end in 
sight.
  Not only does this bill work to solve the problems we see in the 
private insurance market, it addresses one of our Nation's most vital 
programs--Medicaid. This program is a critical lifeline for hundreds of 
thousands of Mississippians.
  Medicaid is a safety net program that was designed for children, the 
elderly, pregnant mothers, and the disabled. This bill will refocus 
attention back on the program's initial goals, but will modernize it to 
better serve these patients.
  We should move decisionmaking authority down to those who are best 
positioned to address these problems. A program run primarily by the 
States with assistance from the Federal Government will best be able to 
help those who need it most.
  By giving States more tools to address costs, this bill will allow 
States to explore ways to make accepting Medicaid more attractive to 
providers, leading to better health outcomes. Without addressing the 
current problems facing the Medicaid program, it will not survive. This 
bill puts Medicaid on a path to sustainability. An insolvent safety net 
will harm those it intends to help.
  This is our moment. We have a historic opportunity to enact the 
biggest entitlement reform in our lifetime. We have a chance to save 
Medicaid.
  I urge my colleagues to vote for this bill.
  Mr. PALLONE. Mr. Speaker, I remind my colleague from Mississippi that 
his vote for this bill will result in 69,600 people from his 
congressional district losing health coverage and care.
  Mr. Speaker, I yield 2 minutes to the gentleman from Texas (Mr. Gene 
Green), the ranking member of the Health Subcommittee.
  Mr. GENE GREEN of Texas. Mr. Speaker, this is outrageous. TrumpCare 
will rip health insurance from 24 million Americans, almost as many 
people who live in the State of Texas.
  TrumpCare is a direct assault on the President's promise to the 
American people. It will saddle families across the country with 
massive health costs. It will lead to higher premiums, less benefits, 
and more people uninsured.
  Under this bill, premiums increase 15 to 20 percent in each of the 
next 2 years. It will particularly be terrible for the near-elderly 
Americans because TrumpCare allows insurance companies to charge them 
five times higher than what others would pay for coverage. It destroys 
protections for Americans with preexisting conditions. It guts the 
essential benefits so consumers won't know what coverage they have. 
Plans would not have to cover things like emergency care, 
hospitalization, or even prescription drugs.
  What do you do when you leave people with that? Junk plans that are 
insurance in name only. What is the point of having insurance if it 
doesn't cover anything?
  For those who aren't one of the 24 million who lose insurance, many 
will be left with plans that are more expensive but don't have to cover 
things like prescription drugs or mental health and substance abuse.
  This bill will make it harder for people to get treatment. It will 
destroy the Medicaid program, the bedrock of our social safety net that 
insures 74 million Americans, including children, pregnant women, and 
one in seven seniors on Medicare.

  TrumpCare harms Medicare. It will make the program insolvent 3 years 
earlier, directly causes part B premiums to go up $8.7 billion, and 
takes away funds that seniors depend on for long-term care. It is 
impossible to overstate how terrible TrumpCare will be for the American 
people.
  This is a dangerous bill. It is opposed by physician groups and 
hospital associations.
  I urge my colleagues to vote ``no.''
  Mr. WALDEN. Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from 
Kentucky (Mr. Guthrie), the former head of the Medicaid task force.
  Mr. GUTHRIE. Mr. Speaker, about 7 years ago, I was on the floor 
talking on the Affordable Care Act. And I remember talking about, I had 
just left the State Senate, and bringing up that my colleagues are in 
Frankfort and they are doing work on the budget; and, in the future, it 
is going to make it more difficult for them to pass budgets because of 
the expansion in Medicaid, and that is coming to pass. It will be in 
the next budget session they have to deal with moving forward, if we 
don't address this situation.
  So people keep talking about a rush process. Over a year ago, we put 
together a Medicaid task force, met with groups of people, met with 
Governors, we took a lot of information, and put together a plan that 
addresses the needs of Medicaid. Medicaid is growing. It will be over a 
$1 trillion program within 10 years if we don't deal with it. It is 
going to implode. So we actually worked to put it on a sustainable 
budget. It is growing. People talk about cuts to Medicaid. Only in 
Washington, D.C., is slowing the growth of a program looked at as a 
cut. So we have worked hard to move that forward.
  The other thing I want to talk about is, last year, small businesses 
were going to be hit by the minimum essential benefits. Small 
businesses were saying: We like our plans, and we want to keep it. We 
are going to have our prices go up, and we are not going to be able to 
afford to provide coverage.
  So we all came together, bipartisan, to address that to exempt the 
small-business plans for those programs. It passed by voice vote in the 
House, unanimous consent in the Senate, and signed by then-President 
Obama.
  So the question is, if small businesses can design and keep their own 
plans, I think individuals can, too.
  I agree with my friend from California that the American people are 
smart. I disagree with my other colleague who says: They will buy 
things, and they won't even know what is in it.
  They are smart, and I urge support for this bill.
  Mr. PALLONE. Mr. Speaker, I remind my friend from Kentucky that his 
vote for this bill will result in 44,000 people from his congressional 
district losing health coverage and care.
  Mr. Speaker, I yield 2 minutes to the gentlewoman from Colorado (Ms. 
DeGette).
  Ms. DeGETTE. Mr. Speaker, President Trump promised his healthcare 
plan would be ``much better health care at a much lower cost.'' 
Secretary of Health and Human Services Tom Price even promised ``nobody 
will be

[[Page H2418]]

worse off financially.'' In reality, of course, the TrumpCare bill will 
leave just about everybody worse off, with less care at a higher cost.
  This bad bill would rip health insurance money away from millions of 
people--24 million over 10 years, and 14 million next year alone.
  Americans who are lucky enough to hold on to coverage if this bill 
becomes law will pay more for it in premiums, deductibles, and other 
out-of-pocket costs, especially people age 50 and up.
  Mr. Speaker, the deals that were cut last night to win more 
Republican votes for TrumpCare would be even more devastating. Trips to 
the emergency room, mental health and substance abuse treatment, 
maternity care both before and after birth, prescription drugs, lab 
tests, and more essential services could be cut.
  Apparently, some people don't think these services deserve guaranteed 
health insurance. They would let insurers sell skimpy plans that don't 
even cover patients' basic needs.
  Democrats believe we can, and should, work together to improve the 
ACA, not to work on a misguided bill that would gut it.
  We owe this to folks like Amanda Miller of Denver. Amanda changed 
jobs last year. During her period of unemployment, she and her husband 
decided the smart thing to do was to get coverage to fill the gap. 
Thank God they did.
  Shortly after that, she and her husband got into a serious car 
accident. Amanda walked away unscathed, but her husband was badly 
injured. She could see more of his skull than she could see of his 
scalp. Luckily, there were some nurses in a car behind them, and they 
stabilized him and took him to the emergency room.
  Their hospital bill of $16,000 was paid in full, thanks to Amanda's 
coverage through the ACA. What do we say to Amanda? Can we guarantee 
her better insurance and a better financial situation? I don't think 
so.
  Let's defeat this bill, and let's start working towards a good one 
that will cover everybody.
  Mr. WALDEN. Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from 
Indiana (Mr. Bucshon).
  Mr. BUCSHON. Mr. Speaker, when ObamaCare was debated 7 years ago, I 
wrote my Member of Congress to urge him to vote against what I saw as a 
government takeover of our healthcare system.
  At that time, I was a practicing physician, and I could foresee the 
disastrous consequences of this law and what it would do to patients 
across this country, including my own. And I wasn't alone.
  Citizens from every corner of America stood up and demanded that 
Congress reject the ObamaCare bill, but we were ignored. Since then, 
out-of-pocket costs for families have skyrocketed, patient-choice has 
evaporated, and ObamaCare has inched closer to the brink of collapse.
  In that time, those same Americans who fought against passage of 
ObamaCare have delivered Republicans majorities in the House, in the 
Senate, and put a Republican in the White House. They did so, in part, 
based on our promises to repeal and replace ObamaCare.

  And here we stand, 7 years after ObamaCare passed, with the 
opportunity to finally deliver on that promise, and to bring relief to 
patients across this country who haven't been able to find the care 
they were promised at a cost they can afford.
  It is an opportunity for us to fulfill our promise to our 
constituents. Let's be clear: a vote against this bill today is a vote 
for preservation of the ObamaCare disaster, a vote to keep critical 
healthcare decisions in the hands of bureaucrats in Washington, D.C., 
and a vote against the largest entitlement reform in a generation.
  I urge all of my colleagues to do the right thing and vote for this 
bill.
  Mr. PALLONE. Mr. Speaker, I remind my colleague from Indiana that his 
vote for this bill will result in 37,800 people from his congressional 
district losing health coverage and care.
  Mr. Speaker, I yield 1 minute to the gentleman from Pennsylvania (Mr. 
Michael F. Doyle).
  Mr. MICHAEL F. DOYLE of Pennsylvania. Mr. Speaker, for the last 7\1/
2\ years, Republicans have promised Americans something better than the 
ACA. Instead, today, they are giving us something much worse.
  Twenty-four million people lose their insurance? Stripping away 
guaranteed benefits? Putting maternity, mental health, and pediatric 
care at risk? Shame on you.
  Pitting the elderly against children, the disabled, and the mentally 
ill in the Medicaid program? Placing a tax penalty on veterans? 
Charging a crushing age tax on 50- to 64-year-olds, forcing them to pay 
five times more than what others pay? Shame on you.
  This isn't a healthcare bill. This is a tax cut bill masquerading as 
a healthcare bill. This bill does nothing to lower premiums, copays, or 
deductibles.
  You cut taxes by almost $1 trillion for corporations and the rich, 
while ransacking Medicaid and the Medicare trust fund. That is 
shameful.
  Americans will not forget who did this to them today.
  Mr. WALDEN. Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from 
Texas (Mr. Flores), a real leader on the Energy and Commerce Committee.

                              {time}  1300

  Mr. FLORES. Mr. Speaker, we have heard numerous comments from the 
left extolling the virtues of ObamaCare, and I think it is instructive 
to hear the words of a former Democratic President that is beloved by 
the left. Here is what he said less than 6 months ago: ``So you've got 
this crazy system where all of a sudden 25 million more people have 
health care and then the people who are out there busting it, sometimes 
60 hours a week, wind up with their premiums doubled and their coverage 
cut in half. It's the craziest thing in the world.''
  Mr. Speaker, hardworking American families in my district, they don't 
want crazy. They want the American Health Care Act, a sane plan that 
gives them their freedom back.
  In a few minutes, Mr. Speaker, you are going to hear somebody from 
the other side say that a bunch of my constituents are going to lose 
coverage. That is absolutely false. Those constituents are getting 
their freedom back to choose whether or not they want healthcare 
coverage and what kind of healthcare coverage they want. I say vote 
``yes.''
  Mr. PALLONE. Mr. Speaker, I remind my colleague from Texas that his 
vote for this bill will result in 61,900 people from his congressional 
district losing health coverage and care.
  Mr. Speaker, I yield 1 minute to the gentleman from North Carolina 
(Mr. Butterfield).
  Mr. BUTTERFIELD. Mr. Speaker, over the last few days, 110 
organizations have written to me in opposition to TrumpCare. You know 
who they are: AARP, American Hospital Association, American Heart 
Association, American Medical Association, American Academy of 
Physicians, American Academy of Pediatrics, American Psychiatric 
Association, National Association of School Nurses, Alliance for 
Retired Americans, American Federation of Teachers, National 
Association of School Psychologists, National School Boards 
Association, National Education Association, the Children's Defense 
Fund, March of Dimes, the National Committee to Preserve Social 
Security and Medicare, the American College of Physicians North 
Carolina Chapter, North Carolina Society of Addiction Medicine, 
Consumers Union, United Steelworkers, AFL-CIO, Families USA, Center for 
American Progress, National Association of Pediatric Nurse 
Practitioners, and the list goes on and on.
  Mr. Speaker, I include in the Record a list of entities opposing 
TrumpCare.

       1. AARP
       2. American Hospital Association
       3. American Heart Association
       4. American Medical Association
       5. American Academy of Physicians
       6. American Academy of Pediatrics
       7. American Psychiatric Association
       8. National Association of School Nurses
       9. Alliance for Retired Americans
       10. American Federation of Teachers
       11. National Association of School Psychologists
       12. National School Boards Association
       13. National Education Association
       14. Children's Defense Fund
       15. March of Dimes
       16. National Committee to Preserve Social Security and 
     Medicare
       17. American College of Physicians North Carolina Chapter
       18. North Carolina Society of Addiction Medicine

[[Page H2419]]

  

       19. North Carolina AIDS Action Network
       20. Consumers Union
       21. SEIU
       22. United Steelworkers
       23. AFL-CIO
       24. Families USA
       25. Center for American Progress
       26. Southern HIV/AIDS Strategy Initiative
       27. National Association of Pediatric Nurse Practitioners
       28. Children's Hospital Association
       29. National Rural Health Association
       30. American Lung Association
       31. ACLU
       32. National Urban League
       33. Black Women's Health Imperative
       34. Communications Workers of America
       35. International Brotherhood of Teamsters
       36. National Rural Education Association
       37. National Association of Social Workers
       38. National Association of Pediatric Nurse Practitioners
       39. Lutheran Services in America
       40. NETWORK Lobby for Catholic Social Justice
       41. Children's Dental Health Project
       42. Family Voices
       43. First Focus Campign for Children
       44. American Psychological Association
       45. National Council for Behavioral Health
       46. National Hemophilia Foundation
       47. American Congress of Obstetriticians and Gynecologists
       48. American Sexual Health Association
       49. Big Cities Health Coalition
       50. National Women's Law Center
       51. Human Rights Campaign
       52. Partnership for America's Children
       53. Friends Committee on National Legislation
       54. National Partnership for Women & Families
       55. Planned Parenthood Action Fund
       56. National Center for Learning Disabilities
       57. Save Medicaid in Schools Coalition
       58. HIV Medicine Association
       59. Drug Policy Alliance
       60. League of Conservation Voters
       61. Natural Resources Defense Council
       62. Green Latinos
       63. Green For All
       64. Safe Climate Campaign
       65. Climate Reality Project
       66. Center for Reproductive Rights
       67. Interfaith Disability Advocacy Collaborative
       68. International Federation of Professional and Technical 
     Engineers
       69. Trust for America's Health
       70. AIDS United
       71. AFSCME
       72. Cystic Fibrosis Foundation
       73. AASA, The School Superintendents Association
       74. Accelify
       75. American Foundation for the Blind
       76. Association of Assistive Technology Act
       77. Programs Association of Educational Service Agencies
       78. Association of School Business Officials International
       79. Association of University Centers on Disabilities
       80. Autistic Self Advocacy Network
       81. Center for American Progress Center for Public 
     Representation
       82. Clearinghouse on Women's Issues
       83. Colorado School Medicaid Consortium
       84. Conference of Educational Administrators of Schools and 
     Programs for the Deaf
       85. Council for Exceptional Children
       86. Council of Administrators of Special Education
       87. Disability Rights Education & Defense Fund
       88. Division for Early Childhood of the Council for 
     Exceptional Children (DEC)
       89. Health and Education Alliance of Louisiana
       90. Healthy Schools Campaign
       91. Higher Education Consortium for Special Education
       92. Judge David L. Bazelon Center for Mental Health Law
       93. LEAnet, a national coalition of local education 
     agencies
       94. Learning Disabilities Association of America
       95. Lutheran Services in America Disability Network
       96. Michigan Association of Intermediate School 
     Administrators
       97. Michigan Association of School Administrators
       98. National Association of Pediatric Nurse Practitioners
       99. National Association of State Directors of Special 
     Education (NASDSE)
       100. National Association of State Head Injury 
     Administrators
       101. National Black Justice Coalition
       102. National Center for Learning Disabilities
       103. National Disability Rights Network
       104. National Down Syndrome Congress
       105. National Health Law Program
       106. National Respite Coalition
       107. Paradigm Healthcare Services
       108. School Social Work Association of America
       109. School-Based Health Alliance
       110. Society for Public Health Education
       111. Teacher Education Division of the Council for 
     Exceptional Children

  Mr. BUTTERFIELD. What is it about this, Mr. Speaker, that you don't 
understand?
  You are wrong on this. Don't let your base push you over the cliff on 
this bill.
  Mr. WALDEN. Mr. Speaker, I yield 1\1/2\ minutes to the gentlewoman 
from Indiana (Mrs. Brooks).
  Mrs. BROOKS of Indiana. Mr. Speaker, I appreciate the passion I have 
heard from colleagues on both sides of the aisle and from Hoosiers on 
all sides of this issue. The issue of health care is personal for 
people, and it should be. But today, health care isn't personal. Under 
ObamaCare, healthcare coverage has been a one-size-fits-all approach.
  I have heard from so many of my constituents in my more than 4 years 
in Congress about how ObamaCare has cost them and their families--lost 
doctors, higher premiums and deductibles, and a lack of options for 
coverage.
  As an example of just one of those Hoosiers, Lon told me his premiums 
and deductibles doubled last year when he lost his healthcare plan. He 
has had to change his insurance 3 times in 3 years. That is not how 
healthcare coverage should work.
  The American Health Care Act makes healthcare coverage more personal 
for every American. This bill empowers you, and every American, to 
choose the best health care for you and your family. It empowers our 
Governors and our State legislatures to meet the individual healthcare 
needs of their citizens, including the people struggling to make ends 
meet and the most vulnerable: the elderly, pregnant moms, kids, and 
people with disabilities.
  I applaud our Hoosier Governor Holcomb, who wrote a letter to 
Congress with other Governors from around the country who support this 
bill, he, too, believes it is in the best interest of Hoosiers. I agree 
and I urge my colleagues to join me in support of the American Health 
Care Act.
  Mr. PALLONE. Mr. Speaker, I remind my colleague from Indiana that her 
vote for this bill will result in 37,700 people from her congressional 
district losing health coverage and care.
  Mr. Speaker, I yield 2 minutes to the gentlewoman from Florida (Ms. 
Castor), the vice ranking member of our committee.
  Ms. CASTOR of Florida. Mr. Speaker, my neighbors back home in Florida 
work very hard for their health coverage. When they pay their hard-
earned copayments and premiums, they expect something meaningful in 
return: real health care. That is what the Affordable Care Act 
provided; not just a piece of paper, but real health services, an end 
to discrimination against preexisting conditions, and all sorts of 
other consumer protections.
  But in the middle of the night last night, the Republicans turned 
back the clock. They have eliminated from the basic health insurance 
policy coverage for emergency room visits, hospitalization, 
prescription drugs, and more.
  They have really embraced the moniker of pay more for less. And on 
top of it, remember, this bill rips health insurance away from millions 
of our neighbors back home. It raises costs on hardworking Americans, 
especially our older neighbors. It is practically an age tax, if you 
are over 50 years old. It breaks that fundamental guarantee that has 
existed for 50 years, that if your family is struck with an Alzheimer's 
diagnosis, a child with a complex condition, a handicap, that you are 
not going to live your remaining years in poverty, all the while, 
taking your tax dollars and shifting it to millionaires and 
billionaires and corporations.
  TrumpCare is a recipe for disaster. It is a fundamental violation of 
the values we share as Americans, and it should meet its demise today.
  Mr. WALDEN. Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from 
New York (Mr. Collins), a real leader on our committee.
  Mr. COLLINS of New York. Mr. Speaker, today is a historic day, make 
no mistake about it. The American Health Care Act changes the 
trajectory of health policy in this country. Here are just a few of the 
highlights:
  This bill eliminates the individual mandate penalty; eliminates the 
employer mandate penalty; eliminates the ObamaCare subsidies in 2020; 
eliminates ObamaCare tax increases; eliminates insurance mandates so we 
can lower premiums; provides refundable tax credits for individuals and 
families who do not get their health insurance through their employer 
or the government, and allows them to choose the health care that works 
for them; almost doubles the contribution limits

[[Page H2420]]

for health savings accounts; provides $115 billion for the Patient and 
State Stability Fund to lower patient cost and stabilize the insurance 
market; and enacts the most significant reforms to Medicaid in history, 
ensuring that Medicaid is sustainable and available for the most 
vulnerable among us for generations to come.
  The American Health Care Act is a monumental step toward freedom, 
choice, and individual responsibility in health care.
  Mr. Speaker, I will proudly vote for this bill today, and I urge all 
of my colleagues to do the same.
  Mr. PALLONE. Mr. Speaker, I remind my colleague from New York that 
his vote for this bill will result in 58,000 people from his 
congressional district losing healthcare coverage and care.
  Mr. Speaker, I yield 1 minute to the gentleman from Maryland (Mr. 
Sarbanes).
  Mr. SARBANES. Mr. Speaker, this is a terrible bill. It is a terrible 
bill. It is wrong for the country.
  Why would the President, why would the leadership on the Republican 
side here in Congress, why would they choose as the first order of 
business taking healthcare coverage away from 24 million Americans?
  It is wrongheaded. It is immoral. It is inhumane. It makes no sense. 
It is wrong for America.
  In the people's House, we need to vote it down.
  Mr. WALDEN. Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from 
Michigan (Mr. Walberg).
  Mr. WALBERG. Mr. Speaker, for 7 years, I have heard story after story 
from people in my district about how the Affordable Care Act is 
anything but affordable.
  Families and small businesses are paying more for less, and insurers 
are dropping out of the marketplaces, leaving behind fewer options. 
Government-run health care isn't working, and we are repealing and 
replacing ObamaCare like we promised our constituents we would do.
  The American Health Care Act is the first step of a three-step 
process to repair our broken healthcare system. This bill moves power 
away from Washington and puts doctors and patients at the center of 
their healthcare decisions. It reforms and strengthens Medicaid and 
gives States the flexibility to innovate and best meet the needs of 
their citizens.
  This patient-centered approach will bring costs down, increase choice 
and competition, and provide important protections for patients with 
preexisting conditions.
  Mr. Speaker, these are the types of things we promised, and doing 
nothing is not an option. May I remind my colleague from the other side 
of the aisle: I have seen those numbers. My constituents will not 
simply walk away and do nothing just because the other side says that 
they will be uncovered. Now they will have a choice. Those thousands of 
people will not walk away. They will choose something better for them. 
There will be thousands of people that have insurance that covers their 
needs, and not what, Mr. Speaker, my colleague says they will do. They 
are not that stupid. They won't walk away.
  Mr. PALLONE. Mr. Speaker, I remind my colleague from Michigan that 
his vote for this bill will result in 39,500 people from his 
congressional district losing health coverage and care.
  Mr. Speaker, I yield 1 minute to the gentleman from California (Mr. 
McNerney).
  Mr. McNERNEY. Mr. Speaker, since the implementation of the ACA, over 
3.9 million women age 18 to 64 have gained health coverage through 
Medicaid. The ACA ended gender rating, meaning that the insurance 
companies cannot charge women more than they charge men for the same 
coverage. TrumpCare also eliminates Medicaid funding for Planned 
Parenthood, reducing access to health care for women. Millions of women 
rely on Planned Parenthood for both routine and lifesaving care, such 
as preventative services, family planning, and preventing unwanted 
pregnancies. When the GPO strips Planned Parenthood funding, health 
care of women will suffer.
  TrumpCare and its Medicare cuts also hurts seniors. Older Americans 
account for over 60 percent of Medicare spending. Insurance companies 
will now be able to charge more based on their age, which will increase 
premiums by thousands.
  Mr. Speaker, watching Republicans sell this bill is like buying a 
used car from a guy with a crooked smile, even they don't believe in 
it. I ask my Republican colleagues to withdraw this horrible bill and 
work with Democrats to improve the ACA instead of trying to sell this 
atrocity.
  Mr. WALDEN. Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from 
Georgia (Mr. Carter), our resident pharmacist on the committee.
  Mr. CARTER of Georgia. Mr. Speaker, I am joyous to be here today on 
such a historical day. You see, for the past 7 years, I have practiced 
in ObamaCare, I have practiced under ObamaCare, and I have practiced in 
that setting; and I can tell you that what it promised, it has not 
delivered on.
  There has not been increased accessibility, no. Instead of that, we 
have got five States in our country that only have one plan to offer. 
We have a third of the counties in our country that only have one plan 
to offer. We have 16 counties in Tennessee that don't even have a plan, 
and now we are going to have the opportunity to have access. Now we are 
going to have choice.
  We have also been told about affordability. Well, let's talk about 
affordability. We see what ObamaCare did. It increased premiums 25 
percent this year alone; 50 percent in seven States. That is 
unsustainable.
  What is our plan going to do?
  It is going to give affordability. It is going to give competition. 
We are going to have choices.
  And what else?
  It is going to remove red tape. It is going to remove the barriers 
between healthcare professionals and patients. It is going to empower 
patients. That is what health care in America is about: people making 
healthcare decisions with their healthcare practitioners. That is what 
we are going to do. That is what this does.
  The two worst things that ObamaCare did to the healthcare system in 
America, first of all, is it took the free market out of America. It 
took the free market out of health care in America. It also expanded 
Medicaid, a safety net program that was intended for the aged, the 
blind, the disabled, children, and mothers, and extended it to able-
bodied adults--something that it was never intended to do.
  Mr. Speaker, I look forward to hearing how many people in my district 
are going to be empowered now from the gentleman from New Jersey.
  Mr. PALLONE. Mr. Speaker, I remind my colleague from Georgia that his 
vote for this bill will result in 62,800 people from his congressional 
district losing health coverage and care.
  Mr. Speaker, I yield 1 minute to the gentleman from Vermont (Mr. 
Welch).
  Mr. WELCH. Mr. Speaker, those of us who support the Affordable Care 
Act know that the work of improving health care and making it more 
affordable and accessible is never done. It matters. It really matters 
to the mothers and fathers we represent and to the children that they 
love. But this bill, stripping 24 million Americans of health care, a 
$1 trillion tax cut to the wealthiest among us, making people 50 to 64 
pay five times as much as other Americans, obviously, is a giant step 
backwards.
  One of those Americans is Linda from Burlington. She left an abusive 
marriage, but had to leave her health care behind. The Affordable Care 
Act rescued her, and she has gone on to revive her life and her future.

                              {time}  1315

  Our community hospitals that do so much good in our communities have 
gone from red ink to black ink by the help that the Medicare expansion 
provided.
  It is a sad day for this institution. We did all of this without 
hearing from a single patient, a single doctor, a single person. We had 
no hearings.
  Mr. Speaker, can we do better than that?
  Mr. WALDEN. Mr. Speaker, I yield 2 minutes to the gentlewoman from 
North Carolina (Ms. Foxx), the chairwoman of the Education and the 
Workforce Committee.
  Ms. FOXX. Mr. Speaker, skyrocketing cost, diminished choices for 
patients, small businesses destroyed, fewer jobs, and lower wages, that 
is

[[Page H2421]]

ObamaCare's legacy. That is what Democrats imposed on our country.
  We believe the American people deserve a better way, and that is what 
this legislation will deliver. The American Health Care Act puts the 
American people back in control of their health care. It restores 
choices, protects the most vulnerable, encourages lower healthcare 
costs, empowers States, and frees families and small businesses from 
costly taxes and mandates.
  Let's keep our promise to provide a better way on health care by 
voting ``yes'' on the American Health Care Act.
  Mr. Speaker, I ask the gentleman from Oregon (Mr. Walden) to engage 
in a brief colloquy.
  Health sharing ministries play an increasingly important role in the 
lives of many Americans, particularly in the devastating wake of 
ObamaCare. In recent days, constituents have expressed concerns about 
the future of these healthcare plans, particularly as it relates to 
whether they would be considered credible coverage under the bill's 
continuous coverage provisions.
  Will Chairman Walden work with me, as the bill moves forward, to 
ensure we address the concerns of those who benefit from health sharing 
ministries?
  Mr. WALDEN. Will the gentlewoman yield?
  Ms. FOXX. I yield to the gentleman from Oregon.
  Mr. WALDEN. Mr. Speaker, I would be delighted to work with the 
gentlewoman from North Carolina.
  Health care sharing ministries are a vital part of our healthcare 
system. They are a shining example of how communities can come together 
without government mandates or dictates to provide innovative 
healthcare solutions.
  I look forward to working with Chairwoman Foxx on these concerns that 
have been raised and will work with the Senate to get repeal and 
replacement of ObamaCare to the President's desk.
  Mr. PALLONE. Mr. Speaker, I remind my colleague from North Carolina 
that her vote for this bill will result in 80,600 people from her 
congressional district losing health coverage and care.
  I yield 1 minute to the gentleman from New Mexico (Mr. Ben Ray 
Lujan).
  Mr. BEN RAY LUJAN of New Mexico. Mr. Speaker, my Republican 
colleagues have called TrumpCare everything from an act of mercy to a 
rescue mission. Now, I might live at the end of a long dirt road, but I 
didn't fall off the turnip truck yesterday and neither did the American 
people.
  Congressional Republicans are jamming their catastrophic bill that 
will take health insurance away from 24 million Americans, raise your 
premiums, raise your deductibles, raise your out-of-pocket costs, and 
will slap a crushing age tax on those over the age of 50.
  Republicans in Congress promised they would lower costs, but this 
mess raises costs on families. Not only does the CBO tell us premiums 
will increase 15 to 20 percent, but TrumpCare will allow insurance 
companies to increase deductibles and out-of-pocket costs.
  Under the guise of State flexibility, Republicans say they are 
shifting responsibilities to States. Here is what that means: TrumpCare 
will force States to raise taxes and ration care. It will repeal the 
requirement for insurance plans to cover doctor visits, emergency room 
care, prescription drug coverage, and even mental health services.
  Everyone is entitled to their own opinions but not their own facts. 
The fact is TrumpCare will raise your premiums, raise your deductibles, 
and hurt millions of hardworking families.
  I urge my colleagues to vote ``no.''
  Mr. WALDEN. Mr. Speaker, I yield 2 minutes to the gentleman from 
Pennsylvania (Mr. Murphy), our resident psychologist who does a 
remarkable job on mental health care issues and all of these healthcare 
issues.
  Mr. MURPHY of Pennsylvania. Mr. Speaker, in my district over the time 
span since the Affordable Care Act, ObamaCare, was passed, I fielded 
many, many a call from persons who said they could not afford health 
care. In some of those instances, even though a person was able to 
afford the premium, they could not afford the deductible.
  A gentleman aged 55 and his wife said they would have to pay $27,000 
out of pocket between premium deductibles and copays before they could 
use their first benefits. He was one of the 19.2 million Americans who 
chose to pay the fine rather than get on the Affordable Care Act, 
ObamaCare. We suspect that many more will continue on with saying they 
would rather pay a fine or find a way out rather than continue to pay 
for it if this continues on as is.
  In the past, we have been battling many things under this with regard 
to mental health care. The past administration attempted to strip the 
protected drug class status for lifesaving psychiatric medications. We 
fought back on that. We also worked together, however, in a bipartisan 
way to make sure we had assured things for mental health care.
  This bill has several provisions which are extremely important. It 
has $100 billion which States may use to help in their stabilization 
fund to fund mental health care. There is another $15 billion focused 
on mental health care. There is $500 billion for substance abuse. 
Funding will be in there.
  My hope is that States make a decision. It is in their hands with the 
passage of this bill so they can make the right choice to continue 
mental health care, and I trust they will do that.

  Mr. PALLONE. Mr. Speaker, I remind my colleague from Pennsylvania 
that his vote for this bill will result in 37,100 people from his 
congressional district losing health coverage and care.
  I yield 1 minute to the gentleman from New York (Mr. Tonko).
  Mr. TONKO. Mr. Speaker, a resounding ``no'' to TrumpCare, President 
Trump's broken promise to our great America. There is no disputing the 
devastation this bill will cause for America's working families.
  TrumpCare will rip health insurance away from 24 million people.
  It will raise costs for consumers and lower standards of care, with 
premiums rising and deductibles increasing by an average of $1,500.
  TrumpCare will eliminate required mental health and addiction 
benefits, jeopardizing recovery for millions of Americans in the midst 
of this opioid epidemic.
  It imposes a crushing new age tax on seniors and those approaching 
retirement, amounting to tens of thousands of dollars.
  TrumpCare steals from Medicare, and it cuts Medicaid by $839 billion, 
mercilessly putting children, the elderly, the disabled, and our most 
vulnerable at risk.
  It does all this to give a $1 trillion tax cut to millionaires, 
billionaires, and corporations.
  The American people overwhelmingly reject this bill.
  Defeat TrumpCare. Vote ``no.''
  Mr. WALDEN. Mr. Speaker, I reserve the balance of my time.
  Mr. PALLONE. Mr. Speaker, I yield 1 minute to the gentlewoman from 
New York (Ms. Clarke).
  Ms. CLARKE of New York. Mr. Speaker, I rise today in strong 
opposition to this sham American Health Care Act.
  I am from Brooklyn, and in Brooklyn we know: Men lie; women lie; the 
numbers don't. Here are the numbers:
  This reckless and destructive bill leaves 24 million Americans 
without coverage. It will cause the uninsured rate for my district to 
skyrocket over 12 percent and leave over 400,000 Brooklynites without 
coverage.
  Because of age discrimination in this bill, the age tax, it will put 
our seniors in the terrible position of having to choose between 
eating, visiting their doctors, or purchasing medication.
  Which one do you, Mr. Speaker, suggest they choose?
  I also vehemently oppose the Empire State kickback language put in 
this bill as an attempt to get Republican votes. This language is a 
dressed up earmark that specifically targets New York City. It targets 
my home.
  This would further reduce Medicaid funds for New York by an 
additional $2 billion. The trade-off, raising city taxes to cover the 
gap.
  For most Americans, Medicaid benefits are not the end goal but rather 
[provides] temporary support, but for our seniors Medicaid can mean the 
difference between nursing home care, family home care and dying alone.
  I urge my colleagues to consider the harmful real life impact of this 
legislation and to oppose it. Brooklyn Resists . . . America must 
resist.

[[Page H2422]]

  Thank you and I yield the balance of my time.
  Mr. WALDEN. Mr. Speaker, I reserve the balance of my time.
  Mr. PALLONE. Mr. Speaker, may I inquire how much time remains on both 
sides?
  The SPEAKER pro tempore (Mr. Collins of Georgia). The gentleman from 
New Jersey has 68 minutes remaining, and the gentleman from Oregon has 
65\1/2\ minutes remaining.
  Mr. PALLONE. Mr. Speaker, what did the Chair say?
  The SPEAKER pro tempore. One hour and eight minutes remaining.
  Mr. PALLONE. Mr. Speaker, I yield 1 minute to the gentleman from Iowa 
(Mr. Loebsack).
  Mr. LOEBSACK. Mr. Speaker, I am disheartened by what Congress is 
doing here today.
  My number one goal has always been to ensure Iowans have access to 
quality, affordable care. This legislation does not do that. It 
implements an age tax, raising costs on older Americans. It cuts nearly 
$900 billion from the elderly, nursing homes, and disabled children.
  This is unacceptable. Exactly those who need health coverage the 
most--middle class families, people with disabilities, and those who 
are less fortunate--are the ones who lose out in this Republican bill.
  I remain committed to working to improve healthcare coverage so it 
works better for Iowans and all Americans. We cannot go back to a time 
when Iowa families had to choose between putting food on the table and 
getting medical care for their children. Unfortunately, that is just 
what this bill does.
  I urge my colleagues to vote this bill down.
  Mr. WALDEN. Mr. Speaker, if I could get an indication in terms of the 
amount we are down on each side here? I think we were allocated a half 
an hour.
  The SPEAKER pro tempore. Is the gentleman referring to the time in 
which he is acting as the designee of the gentlewoman from Tennessee on 
behalf of the Committee on Energy and Commerce?
  Mr. WALDEN. Yes.
  The SPEAKER pro tempore. The gentleman from Oregon has 9\1/2\ minutes 
remaining in the Energy and Commerce portion of this debate.
  Mr. WALDEN. Mr. Speaker, and the minority side? Or is that what is 
remaining split equal?
  The SPEAKER pro tempore. The gentleman will suspend.
  The gentleman from Kentucky has not assigned designees on the basis 
of committee affiliation. The rule provides for four total hours of 
debate.
  Mr. PALLONE. Mr. Speaker, could we just ask the total because then 
maybe we can figure it out on the minority side?
  The SPEAKER pro tempore. The Chair has provided the total time 
remaining for the minority. So that is the total time we are working 
back off of. The Chair will consult with the gentleman on the committee 
time.
  The gentleman from Oregon has 9\1/2\ minutes remaining in the Energy 
and Commerce time.
  Mr. PALLONE. What is the total time remaining currently?
  The SPEAKER pro tempore. There are 67 minutes remaining for the 
gentleman from New Jersey as the designee of the gentleman from 
Kentucky. That is 1 hour and 7 minutes.
  Mr. WALDEN. Mr. Speaker, I reserve the balance of my time.
  Mr. PALLONE. Mr. Speaker, I yield 1 minute to the gentleman from 
Oregon (Mr. Schrader).
  Mr. SCHRADER. Mr. Speaker, after all these late nights and backroom 
deals, here we are. This version of the bill was just dropped on our 
lap this morning, so we ought to take a careful look at what is in 
front of us.
  First of all, the bill defunds access to preventative health care and 
wellness. All the programs that we made progress on will be gone.
  It shortchanges the Medicare trust fund. Seniors might be paying 
thousands more than they are now to get the care they need.
  It returns us to a system with skimpy benefits without serious 
coverage for maternity care and mental health.
  Most dramatically, the bill dismantles the Medicaid system as we know 
it, which has been a success across much of the country.
  In Oregon, children and families finally have access to care that 
fits their needs. People living with disabilities are leading 
productive lives now. Hospitalizations and emergency room visits have 
been cut in half, and costs are down.
  We are all going to do this--take health care away from 24 million 
Americans, 14 million just this next year--and not going to save any 
more money than under the original ACA?
  Look, I know there are parts of the ACA that need fixing. While 
millions of people got coverage for the first time, premiums are still 
too high in the individual market. That is only 5 percent.
  Vote ``no'' on this bill, and let's make the system better.

                              {time}  1330

  Mr. WALDEN. Mr. Speaker, I don't believe I have any other speakers, 
so I will continue to reserve the balance of my time.
  Mr. PALLONE. Mr. Speaker, I yield 1 minute to the gentleman from 
Massachusetts (Mr. Kennedy).
  Mr. KENNEDY. Mr. Speaker, 5 years ago, I got the phone call everyone 
dreads. My wife had collapsed at work and was being rushed to an 
emergency room. It is a moment that is painfully familiar to far too 
many. Time stops. You fight to push your breath down your throat. Your 
brain gets stuck in that highlight reel of worst-case scenarios. You 
are terrified.
  Fortunately, we were among the lucky ones. Lauren was okay. Most 
critically, our health coverage gave us the support that we needed to 
be able to focus on the one thing that mattered most, her recovery.
  For families in America, that is the simple expectation of our 
country's healthcare system, a commitment that our society makes to 
care for one another in our time of deepest need because our health is 
our great equalizer.
  No matter your power or privilege, no one among us escapes our time 
here on Earth without watching someone we love fight for their life. So 
we fortify this social contract, not just out of sympathy for the 
suffering, but so that it is there for us, too, when we need its sturdy 
brace.
  ``Blessed are the merciful, for they shall be shown mercy.''
  Mr. WALDEN. Mr. Speaker, I reserve the balance of my time.
  Mr. PALLONE. Mr. Speaker, I yield to the gentlewoman from California 
(Ms. Lofgren) for a unanimous consent request.
  (Ms. LOFGREN asked and was given permission to revise and extend her 
remarks.)
  Ms. LOFGREN. Mr. Speaker, I rise in opposition to this terrible bill 
that will hurt my constituents in California.
  Mr. Speaker, each one of us was elected by our constituents to stand 
up for them here in Washington. Today, I will stand up for people who 
live in the 19th Congressional District by voting no on this terrible 
bill.
  It's small wonder that polling shows only 19 percent of Americans are 
in favor of this bill. With the bill, 24 million fewer Americans will 
have health care insurance. Families will pay increased out of pocket 
costs with higher deductibles.
  Incredibly, it allows insurance companies to penalize people older 
than 50 by allowing them to charge 5 times more for insurance than 
younger Americans.
  It hurts Seniors in other ways too. . . . by shortening the life of 
the medicare trust funds, by increasing costs for medicine for medicare 
recipients and by smashing the safety net for nursing home care which 
the Medicaid program provides.
  Incredibly, it also has a special penalty for veterans, by barring 
veterans from receiving tax credits if they are nominally eligible for 
VA care, even if there is no room for them at the VA.
  Let's stand together for our hardworking Americans all over our 
country and in our own districts by voting no on this poorly crafted 
bill that cuts taxes for the richest Americans and leaves regular 
Americans on the short end of the stick when it comes to health care.
  Mr. PALLONE. Mr. Speaker, I yield 1 minute to the gentleman from 
California (Mr. Cardenas).
  Mr. CARDENAS. Mr. Speaker, I rise today to urge my colleagues to own 
up to their bad bill. It is clear this is not what the American people 
deserve or what the American people are asking for.
  This legislation guts Medicaid. It steals from Medicare. It crushes 
our seniors and our working families. And

[[Page H2423]]

just when you thought it couldn't get worse, they went after veterans 
and their children.
  What's more, this bill means insurance companies won't cover new 
mothers, newborn babies, and prescription drugs. The Republicans are 
making health care for Americans worse and worse and worse.
  The Republicans have secretly wheeled and dealed in back rooms at the 
expense of millions of Americans in our great country, while giving tax 
breaks to millionaires and billionaires.
  Mr. Speaker, I urge my colleagues to own up to this bill and oppose 
it for the sake of the American people.
  God bless us.
  Mr. WALDEN. Mr. Speaker, I yield myself such time as I may consume.
  One of the great tragedies of this debate is some of the scare 
tactics we have heard. And to listen to the gentleman from California 
talk about how removing essential benefits from the Federal mandate 
from the law is going to cause all that to happen is tragic because he, 
on March 25 of 2015, cosponsored legislation that did precisely that, 
removed the same Federal mandates for workers in the 51-100 pool of 
employees for employers. He said it was too much of a mandate then on 
those businesses, when they provide insurance.
  So every Member of the House who was here then, and every Senator, 
including the Democrat leader of the Senate at the time, voted for 
that, passed unanimously.
  By the way, the Congressional Budget Office said that those 
regulations that we are pulling back here would have made nongroup 
premiums 27 percent to 30 percent higher in 2016, than they otherwise 
would have been. So we are basically taking what CBO said is a good 
policy and implementing it here once again.
  Last time, in 2015, that was bipartisan. It was a voice vote. Today, 
you would think the world was falling around us, the sky was falling. 
Yet, everybody who was here in 2015 said, that is okay, it is the right 
thing to do because it will lower premiums, like CBO said, by 27 to 30 
percent.
  So we thought what was good for those in the work world, for 
everybody who is insured through a large group plan, which is about 155 
million Americans--they don't live under this mandate, yet they have 
all those services and benefits--that that would make sense to lower 
premiums for individuals on the ObamaCare exchange, because what I hear 
is, premiums are too high, deductibles go up.
  Nobody sees this thing coming down. We are making changes here 
because those exchanges are collapsing. We want to bring the premiums 
down. We want to make the changes that will bring them down. CBO says 
doing this on essential benefits would have resulted in nongroup 
premiums 27 to 30 percent lower than they would have otherwise been. 
They basically say they would be higher in 2016 than they would have 
otherwise been. So we are taking that, using that and saying: let's 
drive them down; let's get premiums down.
  It is unfortunate that you were willing to do that 2 years ago. It 
was bipartisan. Today, it is some extraordinary thing we are doing that 
is bad. It is not. We want to get lower premiums.
  Mr. Speaker, I reserve the balance of my time.
  Mr. PALLONE. Mr. Speaker, Chairman Walden is completely 
mischaracterizing the bill that was led by Mr. Cardenas.
  I yield 1 minute to the gentleman from California (Mr. Ruiz).
  Mr. RUIZ. Mr. Speaker, the majority of my patients in the emergency 
department are age 50 and older. This bill's age tax will devastate 
Americans ages 50 to 64 who have worked their whole lives, planned for 
retirement, and now are wondering how they will make ends meet.
  The age tax will force older Americans to pay premiums up to five 
times higher than others, no matter how healthy they are, no matter how 
responsibly they have lived, making coverage too expensive, and forcing 
them to be uninsured.
  For example, Rex, from my district, wrote me that he was worried 
about choosing between affordable insurance or saving for his 
retirement. Insurance for older Americans like Rex will be too 
expensive, leaving them uninsured when they need coverage the most.
  Under this bill, a 64-year-old like Rex, with an income of $26,500, 
in the individual market, will pay up to $14,000 for health insurance. 
That is more than half of their income on premiums alone, leaving 
little for food, for medicine, rent, and other basic necessities.
  I stand with our older Americans, and I urge everyone, Democrats and 
Republicans, to stand with older Americans. Put ideology, partisanship, 
and politics aside and do the right thing.
  Mr. WALDEN. Mr. Speaker, I reserve the balance of my time.
  Mr. PALLONE. Mr. Speaker, I yield 1 minute to the gentleman from 
California (Mr. Peters).
  Mr. PETERS. Mr. Speaker, I came to Congress ready to help improve our 
healthcare system. And as our colleagues on Chairman Walden's side have 
pointed out, there are some insurance markets that aren't providing the 
choice and the low cost that consumers want, so let's fix them.
  But that is not what this bill does. This bill takes away health 
insurance from 24 million Americans, including 37,000 people in my 
district in San Diego. And the last-minute changes made will cost the 
Federal Government even more money, without increasing coverage or 
reducing premiums. Is that really the best we can do?
  The only reason we are in this mess is because the Speaker of the 
House only ever sought 218 Republican votes. That is why we are left 
with a bill that is opposed by doctors, nurses, hospitals, and just 
about everyone because it makes the problems in our healthcare systems 
worse, not better. That is what happens when you never even reach out 
to the other side.

  Whether this bill dies today, or in the Senate, I hope we can get to 
work together, Republicans and Democrats, to do better for the American 
people.
  Mr. WALDEN. Mr. Speaker, I yield myself 30 seconds.
  Actually, we did reach out to Democrats. We have always reached out 
to Democrats. The vice chair of the Committee held lunches with 
Democrats to say: How can we work together on this? And we were told: 
No, we can't work with you on this particular measure. I hope we can. I 
agree, there is a lot we need to do together. It is what the American 
people expect.
  We have had these individual conversations out of the bright lights 
of the cameras. Let's get together. Let's get this done. A lot hangs in 
the balance.
  Mr. Speaker, I reserve the balance of my time.
  Mr. PALLONE. Mr. Speaker, I yield 1 minute to the gentlewoman from 
Michigan (Mrs. Dingell).
  Mrs. DINGELL. Mr. Speaker, today, the House will vote on a bill that 
will take us back in our Nation's history. My family has worked for 
decades for affordable quality health care for every American. It took 
a long time to achieve the progress we have made today.
  We began with Social Security, then we created Medicare, developed 
the National Institutes of Health, the children's healthcare program, 
and many other efforts that have helped every single one of our 
communities across this country.
  Hearing after hearing, amendment after amendment, the Affordable Care 
Act was eventually developed. Coverage was expanded. Costs were 
lowered. Certainty was brought to uncertainty.
  Let me remind you that before the Affordable Care Act, many had to 
decide between bankruptcy and death. Children hit lifetime caps. Cancer 
and being a woman were preexisting conditions where it costs too much 
money for premiums, or you couldn't get them at all.
  Millions now have coverage who didn't, lifesaving screenings, 
preventative care, and, today, we are talking about taking it back by 
eliminating essential services. Please vote ``no'' for America's heart 
and soul.
  Mr. WALDEN. Mr. Speaker, I reserve the balance of my time.
  Mr. PALLONE. Mr. Speaker, I yield myself 1 minute.
  Mr. Speaker, I think it is very telling that the gentleman from 
Oregon has no more speakers on his side for what they claim to be a 
very significant bill, and it certainly is significant; but the reason 
for that, in my opinion, is because this Republican bill is hurting 
real people.

[[Page H2424]]

  Don't tell the real people, don't tell the Americans in my district 
or the rest of the country who are coming to your doors and going to 
your legislative offices and calling you by the thousands to tell you 
not to pass this bill, don't tell them your answer that I hear over and 
over again: Well, trust us. Trust us.
  The problem is we have to look at the bill that is before us today. 
This is a terrible bill. Millions of people, 24 million people, are 
going to lose their insurance. Many more are going to pay a lot more 
out of pocket with higher deductibles and higher copays.
  And the worst part of all is you are allowing the insurance companies 
to sell junk insurance that doesn't even cover their care; it doesn't 
even necessarily provide any coverage.
  So I ask my colleagues on the other side, think of the people. Think 
about your heart. Think about what this really means. And if you look 
at it, you will know that this is a bad bill and should be defeated.
  Vote ``no.'' I urge my colleagues to vote ``no.''
  Mr. Speaker, I reserve the balance of my time.


 =========================== NOTE =========================== 

  
  March 24, 2017, on page H2424, the following appeared: Mr. 
Speaker, I yield back the balance
  
  The online version has been corrected to read: Mr. Speaker, I 
reserve the balance


 ========================= END NOTE ========================= 

  Mr. WALDEN. Mr. Speaker, I yield myself such time as I may consume.
  Mr. Speaker, here is what I would say: What you have heard from the 
other side is everything is working perfectly; leave it alone.
  Democrats created ObamaCare. Democrats created the exchange. They 
said: We are going to tell you the kind of insurance you have to buy; 
we are going to force you to buy it, or you will answer to the IRS and 
pay a penalty. They mandated that.
  Then they came back and said: Well, that didn't work so well, so we 
had better get rid of the essential benefits for the workers and 
employers, 51-100 employees in a company; we are going to take that off 
because that will drive up premiums. And they voted unanimously to do 
that. Today, they come back and say: Oh, that would be horrible. But 
they did it before, so they were for it before they were against it.
  But let me talk about what really matters here. First of all, there 
is lot of scare tactics out there by a lot of high-paid organizations. 
The first is, we preserve your right as a citizen to acquire health 
insurance regardless of your health condition.

                              {time}  1345

  So here is the deal: preexisting conditions, we protect that; 
lifetime caps, we protect that so that insurance companies can't go 
over the top of you; keep your kids on until they are 26, we protect 
that. Those were good things. We agree in a bipartisan way those should 
be protected. We do that.
  But we also recognize that 19.2 million Americans looked at the 
Democrats' healthcare exchanges and plans, went the other direction, 
and said no. They have walked with their wallets and their feet and 
said: I don't like what you are selling and I can't afford what you are 
selling. I will even pay the IRS $600 or $700 not to take ObamaCare.
  Meanwhile, Mr. Speaker, the insurers have said that the way the 
Democrats created the insurance markets all over the country, we can 
stay in them. We are losing too much money, and we are out.
  That is why in one out of three counties today in America you only 
have one choice, and that is called a monopoly. We are trying to fix 
this market so people will have choices that are affordable. We are 
trying to make sure people have access to coverage they want and can 
afford. This is the first step, not the last step, toward fixing this 
market.
  I look at it like we have poured the foundation. Construction 
projects are a little messy when you are just pouring the foundation. 
Now we are going to put up the walls, we are going to put the roof on, 
and we are going to build this out in multiple steps throughout this 
year and next.
  Meanwhile, we provide complete coverage. We do all the protections 
ObamaCare continues in its support for people while we fix the market 
and allow it to come back. We have timed this out. I know there are 
some on my side of the aisle who wanted to get rid of those 
protections, and we brought them around or they are going to vote 
``no.'' But we said: No; we have to have those protections in place--
existing conditions, no more lifetime caps, keeping your kids on until 
they are 26.
  We have a product here that needs to go to the next step. We will all 
work on it and continue to make it better as we go forward. But if we 
do nothing and let it fail today, these markets are going to get worse 
and worse under the Democrats' ObamaCare plans, and people won't have a 
choice in States and counties all over America.
  I wish we could join together today and put forward a bipartisan vote 
to save these markets and help our constituents going forward. Mr. 
Speaker, we owe it to them. They have asked for it for 7 years. Let's 
get it done.
  Mr. Speaker, I urge support for this legislation, and I reserve the 
balance of my time.
  Mr. PALLONE. Mr. Speaker, I yield the balance of my time to the 
gentleman from Massachusetts (Mr. Neal), and I ask unanimous consent 
that he be allowed to control that time.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from New Jersey?
  There was no objection.
  Mrs. BLACK. Mr. Speaker, I yield 30 minutes to the gentleman from 
Texas (Mr. Brady), and I ask unanimous consent that he may control that 
time.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentlewoman from Tennessee?
  There was no objection.
  Mr. BRADY of Texas. Mr. Speaker, I yield myself such time as I may 
consume.
  Mr. Speaker, last month, President Trump stood right here in this 
room and said to Congress: ObamaCare is collapsing. He called on us to 
take decisive action to protect all Americans.
  Today we have a choice to make: will we answer the President's call 
to action and pass this legislation to repeal and replace ObamaCare? Or 
will we allow ObamaCare to remain fully in place and deny our 
constituents the relief they urgently need?
  I, for one, refuse to allow my constituents in Texas to suffer 
ObamaCare's impacts any longer. For the past 7 years, we have watched 
ObamaCare fail Americans on every single promise, and throughout this 
time, as the Obama administration turned a deaf ear to the American 
people, House Republicans were listening. We were listening to all 
those facing severe premium increases, people like Lauren in my 
district, in my hometown of The Woodlands. Lauren recently emailed me 
to say that her premiums this year have gone up by nearly 70 percent. 
Now they are $900 a month.
  We were listening to all those who can no longer see the doctor of 
their choice or access the care they need at an affordable price, 
people like Elizabeth from Conroe, Texas, another constituent of my 
mine. Her family pays about $800 a month in healthcare premiums, yet 
they can no longer see any of the doctors they know and trust. This 
includes the primary care doctor that Elizabeth and her husband have 
been seeing for over a decade. It includes her children's longtime 
pediatrician. All of these doctors are now out of reach, thanks to 
ObamaCare.
  That is the thing with this law. It has helped some, no doubt, but 
far more people have been hurt, people like Lauren and Elizabeth, who 
are paying significantly more for significantly less access to health 
care.
  It doesn't have to be this way. After 7 years of listening carefully 
to the American people, we have now arrived at this moment of decisive 
action. With the American Health Care Act, we have the best opportunity 
since ObamaCare's enactment to repeal this harmful law, clear the deck, 
and begin over with a step-by-step process to deliver a healthcare 
system based on what patients and families truly want and need, not 
what Washington thinks is best.
  This bill gets us off to an excellent start. First, it delivers swift 
relief to the American people by immediately repealing ObamaCare's most 
harmful provisions. The individual mandate--the tax penalty--is gone. 
The employer mandate tax penalty is gone. Nearly $900 billion in 
ObamaCare tax hikes that have driven up costs and reduced access to 
care for families, patients, and jobs, those tax hikes are gone.

  From here, the American Health Care Act takes significant action to 
replace ObamaCare with patient-focused solutions that expand choice, 
lower

[[Page H2425]]

costs, and enhance competition. This is where we reclaim control of 
health care from Washington and put it back where it belongs--with 
patients, families, and States.
  We expand health savings accounts, making them more flexible and more 
user-friendly. We protect health coverage for the more than 150 million 
Americans who receive it through their job. We deliver the largest 
entitlement reform in decades, giving power to States to improve and 
streamline Medicaid so they can better serve the needs of local 
patients and families.
  For low- and middle-income Americans who don't receive coverage 
through work or a Federal program, we offer an advanceable, refundable 
tax credit that people can use immediately to help purchase coverage 
that is tailored to their needs. These tax credits provide a 
conservative, free-market alternative to inefficient ObamaCare 
subsidies that exist today. They deliver support to low- and middle-
income Americans. At the same time, they will encourage real 
competition and choice in the health insurance market.
  Finally, as a committed pro-life conservative, I am pleased to say 
this bill defunds Planned Parenthood while funding the community health 
centers for women's truly needed health care, and takes vital action to 
protect the right to life. No Federal funding can be used for elective 
abortions. The language is crystal clear.
  The American Health Care Act represents a critical first step in our 
multiphase effort to tear down ObamaCare and reinstate patient-focused 
solutions that help all Americans. But we know there is more work to 
do. ObamaCare was a massive government takeover of health care. To 
fully uproot the law, it is going to take a sustained, coordinated, and 
relentless effort from both Congress and the administration. 
Fortunately, we have incredible partners in President Trump and 
Secretary Price at the Department of Health and Human Services. They 
are already beginning work on the next phases of the process, stripping 
away ObamaCare's regulations so we can enact additional free-market 
solutions. These include consensus conservative proposals, such as 
allowing insurance to be sold across State lines.
  But to see success in the next phases, we have to take the first step 
today. We have to pass the American Health Care Act, deliver immediate 
relief to the American people, and provide a conservative path forward.
  In closing, I thank all the leaders in the House who worked hard to 
craft the bill before us today: Chairman Greg Walden, Chairman Diane 
Black, and so many others.
  I also want to offer my gratitude to everyone from the Congressional 
Budget Office, the Joint Committee on Taxation, and the House Office of 
Legislative Counsel who provided analysis and support as we developed 
this legislation.
  I would like to give a special thanks to Emily Murry, Stephanie 
Parks, and all of our hardworking staff on the Ways and Means 
Committee.
  At the end of the day, on this day, we will have our first true vote 
to repeal ObamaCare. History will record where we stand. This is a 
clear choice. We can stand with President Trump and more freedom for 
Americans to buy health care they choose, or stand with ObamaCare and 
more government that gets in the way. I proudly stand with President 
Trump and more freedom for the American people.
  Mr. Speaker, I reserve the balance of my time.
  Mr. NEAL. Mr. Speaker, I yield myself such time as I may consume.
  Recently, President Trump said: Who knew that health care could be so 
complicated?
  Well, 70 years ago, Harry Truman knew how complicated it could be 
when he first proposed national health insurance. Lyndon Johnson knew 
more than 50 years ago when he proposed, successfully, Medicare and 
Medicaid. Richard Nixon knew when he proposed the individual mandate. 
Bob Dole knew when he proposed the individual mandate. In 
Massachusetts, Mitt Romney knew when he proposed the individual 
mandate.
  Mr. Speaker, recently, within the last week, the great on-the-street 
writer, Jimmy Breslin, died. Amongst the great columns and the great 
books he wrote, one of them that he wrote that will be with us in a 
timeless manner was ``The Gang That Couldn't Shoot Straight.''
  That is what this institution has been like for the last 10 days. 
There were caucuses and there were conferences. People were running 
back and forth with new CBO scores and coming back to the floor with 
new proposals. Members are put in the position of being offered special 
arrangements so that they might be brought over the goal line--that, 
after 61 times they have voted in this House to try to repeal the 
Affordable Care Act.
  Well, here is what we have in front of us this afternoon: a CBO score 
says that 24 million Americans will see either an increase in premiums 
or they will lose their insurance, there will be an imposition of an 
age tax on older Americans, and a tax cut of $1 trillion. This bill has 
gone from bad to worse.
  If that wasn't enough, to get the votes to pass the bill, they want 
to cut prescription drug benefits, mental health benefits, hospital 
benefits, and maternity care; and, yes, every one of us in this 
institution knows a family who is struggling with a loved one's 
addiction, and they want to roll back that benefit.
  Recently, the conservative columnist Bill Kristol tweeted:

       The healthcare bill doesn't, A, lower costs that they have; 
     B, it doesn't improve insurance; C, it doesn't increase 
     liberty; D, it doesn't make health care better. So what is 
     the point?

  Here is the point: it is a $1 trillion tax cut so that they can 
change the baseline for their tax cuts that are coming down the road. 
That is what this is about.
  Now, the President said he wanted an insurance plan that covered all 
members of the American family. What they are offering up today is a 
plan that cuts health insurance for 24 million American family members. 
It does not increase coverage, it does not lower costs, and it does not 
strengthen consumer protections.

  So what does it do?
  Sadly enough, back to the old argument that we have had in this 
institution for years: a $1 trillion tax cut for the people at the top 
and special interests.
  The former speaker here a minute ago, the chairman of the Energy and 
Commerce Committee, spoke about perfection. I was here when this 
legislation was authored, and I helped to write it. I can tell you this 
right now: we knew it was not about perfection, but we subscribed to 
the idea, as was the case with Social Security, Medicare, and Medicaid, 
that we would improve it as time went on. We would fix it so that all 
members of the American family might benefit from the basic notion of 
access and affordability as it relates to health care.
  So what do we have here?
  $839 billion of cuts to Medicaid, which is now long-term care for 
members of the American family.
  Do you know why?
  Sixty percent of Medicaid dollars go to nursing home care, and they 
want to cut $839 billion to provide a $1 trillion tax cut. Let me tell 
you, members of the American family can understand that.
  In Massachusetts, where proudly I can say 100 percent of the children 
in our State are covered, 97 percent of the adults in Massachusetts are 
covered. And guess what? It polls regularly in the high seventies as to 
consumer satisfaction. A Republican Governor of Massachusetts has 
advised them to go slowly and to go carefully, that this is not the 
path that they want to travel down, as well as other Governors across 
the country who happen to be a Republican.

                              {time}  1400

  The hard truth here today is they are asking the American family to 
pay more to get less. Dozens of Republicans have said so today.
  Secretary Mnuchin recently said that ``there will be no absolute tax 
cut for the upper class.'' I hope that the Republican Conference 
confers with Secretary Mnuchin so that they might get their facts 
straight on this issue.
  Mr. Speaker, I reserve the balance of my time.
  Mr. BRADY of Texas. Mr. Speaker, I yield 3 minutes to the gentleman 
from Ohio (Mr. Tiberi), the chairman of the Health Subcommittee, who 
played an invaluable role in solutions to lower healthcare costs for 
Americans.

[[Page H2426]]

  

  Mr. TIBERI. Mr. Speaker, I thank the gentleman for his leadership in 
this important matter, and I echo his words with respect to the staff, 
Emily Murry and her team, as well as Whitney Daffner and Abby Finn in 
my office.
  Mr. Speaker, like the chairman, I had a front row seat in 2009 and 
2010 to the passage of the Affordable Care Act and a front row seat to 
all the promises made about this wonderful bill called the Affordable 
Care Act.
  Then, over the last 6 years, like the chairman, I heard from my 
constituents and fellow Ohioans. I heard about their sad ObamaCare 
stories of a road of broken ObamaCare promises.
  There was a lady east of Columbus who had cancer. She was a survivor. 
Fast-forward to a few years ago. She gets cancer again and finds out 
that the oncologist that she had, she could no longer have. He was not 
in the network. She could not go to the hospital in her community. She 
had to go 60 miles away.
  Or there is the small-business owner and his wife and family on the 
individual market and now on the exchange not getting employer-provided 
health care and, therefore, not getting the benefit. They saw their 
plan price quadruple in the last several years. Mr. Speaker, we are 
going to take care of that person and give them a tax credit so they 
have the ability, just like employer-provided employee's health care.
  In Ohio, last year, our CO-OP collapsed. We had 20,000 people without 
health care. Many saw bills not being paid. Twenty counties in my State 
had one provider and fewer choices.
  Broken promises. Constituents can't keep their doctor, can't keep 
their hospital. Constituents saw emergency room visits go up. It was 
supposed to go down under the Affordable Care Act. Premiums and 
deductibles are going up, not down, in my district.
  One promise wasn't broken, and that is a government-mandated, one-
size-fits-all Washington plan that many of my constituents didn't want 
and others couldn't afford. That was their ObamaCare.
  We can do better, and in this bill we do. In one step, in the first 
step, more steps to come, we begin creating a patient-centered 
healthcare system that will not only put more power in the hands of our 
constituents, but it will also drive down healthcare costs.
  Remember what they said in Ohio newspapers in my State about 
ObamaCare: a tough pill to swallow, a nightmare, very taxing, just more 
red tape. These aren't my words, Mr. Speaker; these are hardworking 
Ohioans' words. They deserve better. They deserve more choices. They 
deserve better access, the access and the choices they want for them 
and their families.
  We begin, Mr. Speaker, with this bill. We don't end here. There is 
much more to do. We are putting the people's power back in their hands, 
not in Washington's hands. Today, it is time for us to deliver.
  Mr. NEAL. Mr. Speaker, I would remind my friend--and he is my 
friend--from Ohio that his vote will result in 39,500 people losing 
their healthcare coverage if this legislation prevails.
  Mr. Speaker, I yield 2 minutes to the gentleman from Michigan (Mr. 
Levin), who was a substantive and major player in the development of 
the ACA when it was passed.
  (Mr. LEVIN asked and was given permission to revise and extend his 
remarks.)
  Mr. LEVIN. Mr. Speaker, I thank Mr. Neal for his work and that of all 
of us on the committee on the Democratic side.
  As CBO has said, under this bill, 24 million Americans would lose 
their health insurance next year, and 24 million over the next decade.
  Today, most are invisible, but they would become seen and heard at 
emergency rooms, with no other place to go with more serious illnesses 
because of no preventive care.
  They are people 50 to 64 with far higher premiums; mothers without 
access to affordable maternity care; elderly evicted from nursing 
homes, losing coverage from Medicaid, the largest source of long-term 
care in our Nation; and lives lost that could have been saved. I 
repeat: lives lost that could have been saved.
  I remember some time ago I met a woman who had health insurance 
through her job. She contracted breast cancer and received treatment 
but then lost her job and insurance. Then the ACA covered her. She 
looked straight at us and said that, without further treatments, she 
would not be alive today.
  Under this bill, a trillion dollars is lost for health care, and 
there will be a trillion dollars in tax cuts, mostly for the very 
wealthy and corporations.
  This is not America. I repeat: This is not America.
  Mr. BRADY of Texas. Mr. Speaker, I yield 2 minutes to the gentleman 
from Nebraska (Mr. Smith), the chairman of the Human Resources 
Subcommittee.
  Mr. SMITH of Nebraska. Mr. Speaker, I rise today in support of H.R. 
1628, the American Health Care Act of 2017. This legislation is the 
first step in a process to unravel ObamaCare's taxes and mandates and 
provide relief to the American people.
  To understand the extent of ObamaCare's failures and their impact on 
hardworking Americans and their families, just look at the rapid 
collapse of ObamaCare's Consumer-Operated and Oriented Plans, or CO-
OPs.
  The story of these failed ObamaCare CO-OPs began in my home State of 
Nebraska, with the abrupt collapse of CoOportunity Health, which left 
120,000 Nebraskans and Iowans without health insurance. I repeat: It 
left 120,000 Nebraskans and Iowans without health insurance.
  CoOportunity Health was the first ObamaCare CO-OP to collapse, but it 
wasn't long before 18 more followed suit, closing their doors and 
leaving hundreds of thousands more without health insurance. Only 4 of 
the 23 CO-OPs created under ObamaCare actually remain, and these 
remaining 4 will likely face the same fate as they continue to struggle 
with dire financial challenges.
  Americans were falsely promised, if they liked their insurance, they 
could keep it. After complying with ObamaCare's mandates, many 
Nebraskans could not even keep the insurance this law created.
  One of my constituents in western Nebraska, Pam, who is self-
employed, lost her insurance four times under ObamaCare. Prior to 
ObamaCare's implementation, she had a plan she liked and that actually 
covered her preexisting condition. She was forced off of that original 
plan when ObamaCare began and then lost her coverage three more times 
through no fault of her own.
  For Pam and millions of others across the country, ObamaCare has 
severely limited options for affordable care. This is simply 
unsustainable. Constituents in rural districts like mine are being hit 
the hardest by ObamaCare's dwindling insurance markets. Because of 
ObamaCare, Nebraskans are down to only two insurers from which to 
choose, and other rural areas are down to only one or even zero 
providers on their exchanges.
  Adding insult to injury, according to the Obama administration's own 
report on the individual market, 2017 premiums in Nebraska increased by 
51 percent.
  The SPEAKER pro tempore. The time of the gentleman has expired.
  Mr. BRADY of Texas. Mr. Speaker, I yield the gentleman an additional 
30 seconds.
  Mr. SMITH of Nebraska. Mr. Speaker, places like Oklahoma are 
experiencing premium increases of 69 percent, and it is only projected 
to get worse if we do not act.
  Doing nothing is certainly not an option. We must come together to 
rescue this rapidly collapsing healthcare system. Let's come together 
to do right by the American people.
  I urge passage of this bill.
  Mr. NEAL. Mr. Speaker, I would remind my colleague that his vote for 
this bill will result in 50,000 people in his congressional district in 
Nebraska losing their health coverage and care.
  Mr. Speaker, I yield 2 minutes to the gentleman from Georgia (Mr. 
Lewis), a giant in terms of the morality of our time and a good friend 
and individual who helped write the Affordable Care Act, as well.
  Mr. LEWIS of Georgia. Mr. Speaker, I want to thank my friend for 
yielding.
  Mr. Speaker, I rise to oppose this bill.
  As elected Representatives, we have a mission, an obligation, and a 
mandate to fight for each and every American.

[[Page H2427]]

  I ask you, Mr. Speaker: Who will stand for the American people? Who 
will speak up for those who have been left out and left behind?
  Mr. Speaker, I have said it time and time again: Health care is a 
right. It is not a privilege reserved for a wealthy few, for what does 
it profit this body to pass this bill and lose our soul?
  This bill is a shame. It is a disgrace.
  Mr. Speaker, today my heart breaks for the disabled, for women, for 
seniors, and for working families. My heart aches for those who are 
living paycheck to paycheck. My heart mourns for innocent little 
children whose very lives depend on if their families can pay the 
bills.
  This is the right and wrong of it. This is the heart and soul of the 
matter.
  We cannot abandon our principles, Mr. Speaker. We cannot forget our 
values. I have fought too hard and too long to back down now.
  I will fight any bill that turns the clock back to a darker time. I 
will fight every single attempt to turn a deaf ear, a blind eye, and a 
cold shoulder to the sick, to our seniors, and to working families.
  Mr. Speaker, I will fight every day, every hour, every minute, and 
every second. I oppose this bill with every breath and every bone in my 
body. We must not give up. We cannot--I will not--give in, not today, 
not tomorrow, not never, ever.
  On this bill, there is only one option, and that option is to vote 
``no.'' We can do better. Mr. Speaker, we must do better. Vote ``no'' 
on this bill.
  Mr. BRADY of Texas. Mr. Speaker, I first would remind my friend from 
Georgia that nearly 700,000 Georgians have chosen to either pay a fine 
or exempt themselves from ObamaCare because it has failed them so 
badly.
  And to my friend from Michigan, 420,000 Michiganders, more than half, 
chose to exempt themselves from ObamaCare rather than accept that 
failed health care.
  Mr. Speaker, I yield 2 minutes to the gentleman from Minnesota, (Mr. 
Paulsen), a key member of the Ways and Means Committee.
  Mr. PAULSEN. Mr. Speaker, today we are taking a very important step 
to lift the burden of the Affordable Care Act off of the backs of the 
American people. A key component of this is repealing the burdensome 
mandates and tax increases that were imposed to help fund this failed 
law. This includes the medical device tax, a senseless policy that 
placed an excise tax on lifesaving medical technology.

  What did this achieve? A loss of 30,000 high-paying American jobs, 
less research and development, canceled projects, and postponed 
expansions. Most importantly, it hurt patients.
  There is good news. Just a few years ago, in 2015, we came together 
on a bipartisan basis and suspended the tax for 2 years. We are seeing 
positive results. Companies are now hiring again, we have increased 
research and development, and we have new investments in facilities 
coming online.
  We need to permanently repeal this onerous tax or it is going to 
start up again. Voting ``yes'' today means permanent repeal of the 
medical device tax.
  Mr. Speaker, I am also encouraged to see several provisions I have 
authored to enhance and expand the use of health savings accounts and 
flexible spending accounts that are included in this legislation today.
  HSAs and FSAs are now more popular than ever and used by 20 million 
Americans. It is time to remove the restrictions on HSAs that were 
imposed in ObamaCare so that we can make them more accessible and 
easier to use and empower Americans to take more control of their 
healthcare decisions.
  Expanding HSAs will help us also begin to address the rising costs of 
health care. One recent study showed that, when a large employer 
switched their employees over to an HSA plan, it lowered their 
healthcare spending by an average of $900 per employee over a 5-year 
period. That is real savings, Mr. Speaker.
  Let's support a better way forward to lower healthcare costs for 
patients and put them back in control of their healthcare decisions.

                              {time}  1415

  Mr. NEAL. Mr. Speaker, I remind my colleague that his vote for this 
bill will result in 49,200 people in his congressional district in 
Minnesota losing their healthcare coverage and care.
  Mr. Speaker, I include in the Record a letter from Governor Charlie 
Baker of Massachusetts that relates to the debate we are having today.

         Office of the Governor, Commonwealth of Massachusetts, 
           State House,
                                       Boston, MA, March 21, 2017.
       Dear Delegation Member: Health care is once again at the 
     forefront of national and state policy discussions; I know we 
     all share the goal of ensuring access to quality, affordable 
     health care coverage for the people of Massachusetts. With 
     Congress set to take up the American Health Care Act (AHCA) 
     imminently, I wanted to share with you my administration's 
     analysis of the potential effects this bill would have on our 
     state.
       The Congressional Budget Office (CBO) released its score of 
     the AHCA on March 13. This analysis is broadly consistent 
     with concerns we have raised, with you and others, regarding 
     the bill's impact on the state and its residents' access to 
     affordable healthcare. Applying CBO's assumptions to 
     Massachusetts results in at least $1 billion of reduced 
     federal revenue beginning in 2020, and we estimate reduced 
     revenue of $1.3 billion in 2021, and $1.5 billion in 2022, 
     with likely a greater annual impact in the years that follow.
       Specifically, our estimate extrapolated from the CBO 
     analysis of a $1.5 billion impact for FY 2022 includes $1.3 
     billion of annual MassHealth federal revenue losses and $200 
     million in annual reduced federal subsidies for private 
     insurance through the Connector.
       Several key areas of concern for Massachusetts were not 
     included in the CBO analysis and could further impact the 
     Commonwealth's budget. For example, the CBO estimate does not 
     address 1115 waiver payments that we believe this bill would 
     put at risk. By FY22, the Commonwealth estimates an 
     additional $425-475 million per year of reduced federal 
     revenue in potential elimination of 1115 payments not 
     captured under the per capita targets, including federal 
     matching funds for a state-run ConnectorCare Wrap subsidy.
       The actual experience for these and other factors is 
     significantly dependent on how the U.S. Department of Health 
     and Human Services implements the legislation and 
     unpredictable factors in the future (e.g., pharmaceutical 
     growth).
       In addition to reduced federal revenue for Medicaid, the 
     CBO also projects a reduction in employer-sponsored health 
     insurance of 7 million people nationwide as a result of the 
     repeal of the federal Employer Mandate. This would exacerbate 
     a trend that Massachusetts has seen over the last several 
     years. Massachusetts repealed the Chapter 58 Fair Share 
     Contribution in 2013 in order to comport with the ACA. My 
     administration has proposed reinstating an employers' shared 
     responsibility for the costs of health care. This would be 
     increasingly important if the federal Employer Mandate were 
     repealed, as the AHCA proposes.
       The Commonwealth does have certain protections in place 
     that could mitigate the impact of some of these changes. 
     Massachusetts retains its individual health insurance 
     mandate, reducing the likelihood that many people would drop 
     out of the insurance market due to the repeal of the federal 
     mandate. Massachusetts also has protective insurance coverage 
     laws that would not be superseded by the federal legislation.
       The AHCA includes a provision that would prevent Medicaid 
     from reimbursing Planned Parenthood for providing important 
     health services such as cancer screenings. My administration 
     opposes this provision, and has already committed to funding 
     these services with state dollars if it should pass.
       During conversations with governors across the country, the 
     Trump Administration has expressed a general openness to 
     providing greater state flexibility with respect to health 
     care, including through a letter issued by HHS Secretary 
     Price on March 14 to states. Our administration will pursue 
     additional flexibilities to stabilize our markets and ensure 
     continued coverage for residents and we urge you to support 
     these efforts by leading discussions in Congress to ensure 
     the people of Massachusetts continue to have access to a 
     quality health care system.
       Overall, our analysis indicates that the AHCA would 
     increasingly strain the fiscal resources necessary to support 
     the Commonwealth's continued commitment to universal health 
     care coverage. I hope this information is helpful to you as 
     Congress takes up the American Health Care Act.
       My administration and I will continue to stay in touch with 
     you as we work together to ensure access to quality, 
     affordable health coverage for all Massachusetts residents.
           Sincerely,
                                                 Charles D. Baker,
                                                         Governor.

  Mr. NEAL. Mr. Speaker, I yield 2 minutes to the gentleman from Texas 
(Mr. Doggett), who played a major role in the substantive contribution 
he made to writing the ACA.
  Mr. DOGGETT. Mr. Speaker, TrumpCare is big on Trump, but it is weak 
on care. After falsely promising that there would be coverage for 
everyone for less and better, TrumpCare only cares about huge tax 
breaks for the superrich and special interests, like

[[Page H2428]]

the totally unjustified $28 billion windfall for the pharmaceutical 
industry that they grab right out of the Medicare trust fund so that 
premiums will go up. Those earning $1 million within a single year get 
79 percent of a $230 billion tax break, but there is no genuine relief 
for middle class taxpayers.
  Removing the essential health benefits provisions will only enable 
insurers to exclude the very healthcare protections that folks thought 
they were getting when they paid their premiums. Insurance plans will 
not just be skinny, they will be a sham; a provision that at the very 
time you need the care, it won't be there. Many certificates of 
insurance will become as worthless almost as a diploma from Trump 
University.
  This Republican bill targets our veterans by denying them tax 
credits. For millions of people who are just a few years too young to 
qualify for Medicare, their premiums will go through the roof. It will 
cost thousands of dollars more in order to get insurance. Yes, the 
Republicans have been divided and factionalized. They are divided 
between those who want nothing care and those who want little care. 
But, mostly, they don't seem to care how many millions of people lose 
their health insurance.
  Mr. President, this is not the art of the deal. It is the art of the 
steal, of taking away insurance coverage from families that really need 
it to provide tax breaks for those at the very top. Those who 
understand health care, the professionals, say reject this bill, and it 
should be rejected.
  Mr. BRADY of Texas. Mr. Speaker, I remind my friend from Texas that 2 
million Texans eligible, forced into ObamaCare and getting deep 
subsidies, have said: No thanks. ObamaCare has failed me.
  Two out of three Texans eligible.
  Mr. Speaker, I yield 2 minutes to the gentleman from New York (Mr. 
Reed), a key member of our Committee on Ways and Means.
  Mr. REED. Mr. Speaker, I rise today in support of this legislation. I 
ask my colleagues on the other side of the aisle--as I stood in front 
of town halls and I listened to thousands of folks across my district 
say what we should be working on is fixing the Affordable Care Act to a 
T, I have heard my colleagues on the other side of the aisle say: It is 
not perfect; we need to repair it.
  Yet, today we take the first step in this endeavor by the legislation 
that is before us, and all we hear is how bad this legislation is. All 
we hear today, Mr. Speaker, is how bad this first step in this journey 
for the American people we need to go on when it comes to American 
health care is.
  I don't hear rhetoric saying let us talk about phase 2, let us talk 
about phase 3, where we can come together as Democrats and Republicans 
for the people we represent.
  The American people are lost in this bickering that we have here in 
this Chamber today, but I don't forget their voice. I am not going to 
forget the voice of the constituents that came to me as small-business 
owners saying: You are putting me out of business with these insurance 
premiums. They are going through the roof.
  I won't forget the faces of the people who are saying: My copays are 
going through the roof. My deductibles are higher. I don't have 
coverage that I had 7 years, 8 years ago before ObamaCare.
  Mr. Speaker, I implore all of us in this Chamber to work together for 
the American people as a whole. The American people want freedom. They 
don't want mandates. They want to choose the insurance that works best 
for them. They want to access their doctors that they select. They want 
to have the promise that was made to them, that they could have their 
insurance and keep it going forward honored and respected by this 
institution. That is what our legislation starts today.
  Not a soul on our side of the aisle says the issue of health care 
will go away because of the first step we take today, because we have 
to do better for the American people when it comes not only to health 
insurance, but for health care in America. I know we can, and I want to 
be a voice to say let us join together to get this done for the 
American people.

  Mr. NEAL. Mr. Speaker, I remind my colleague that his vote for this 
bill today will result in 68,300 people from his congressional district 
losing their health coverage and care.
  Mr. Speaker, I yield 1 minute to the gentleman from California (Mr. 
Thompson), a very thoughtful member of the Committee on Ways and Means 
who also helped to write the ACA.
  Mr. THOMPSON of California. Mr. Speaker, I rise in opposition to this 
bad bill. It is not a step toward fixing the ACA, this is a step toward 
destroying health care. It was bad when it ripped health care away from 
24 million Americans. It was bad when it created an age tax, forcing 
seniors to pay five times that of what other people pay. It was bad 
when it forced hardworking Americans to pay higher premiums and 
deductibles while billionaires get a trillion dollars' worth of tax 
cuts. And it was bad when it shortened the life of Medicare.
  But today it got worse. Today Republicans gutted coverage for 
emergency services, prescription drugs, hospitalization, mental health 
coverage, and preventative coverage. This bill also prevents millions 
of veterans from getting health care. This is a truly bad bill. It will 
cost millions of Americans their health care. It will force them to pay 
more for fewer benefits, and it gives the richest Americans a huge tax 
cut. This is a tax-cut bill, not a healthcare bill. The American people 
deserve much better. I urge everyone to vote ``no'' on this bad bill.
  Mr. BRADY of Texas. Mr. Speaker, I remind my friend from California, 
1.5 million Californians forced into ObamaCare and given generous 
subsidies found a way to exempt themselves because ObamaCare failed.
  Mr. Speaker, I am proud to yield 3 minutes to the gentleman from 
Pennsylvania (Mr. Kelly), a small-businessman and a key member of our 
committee.
  Mr. KELLY of Pennsylvania. Mr. Speaker, I am proud to stand today in 
support of this bill. I have been told that this is a rookie mistake. I 
understand that. We have been working 7 years to undo that rookie's 
mistake. That is why we are here today. A rookie who didn't know what 
he was doing, but lectured to us, told us: This is what you have to do; 
and if you do this, you can keep your doctor, you can keep your health 
plan, you can just stay on board, and we are going to insure millions 
of you.
  Nothing could be further from the truth. The big thing was you are 
going to save $2,300 on your premiums. He forgot to tell everybody but 
the people who were actually in that business. Incredible. Incredible.
  Now, this isn't about me, and it is not about you. This is about 
people. We are in the people's House. Let me just read to you a couple 
letters from the people who I represent back home. By the way, out of 
the seven counties I represent, five have one insurer, and the rest of 
them got out because they couldn't stand to try and work under this 
onerous law.
  Let me tell you what Amanda says: I am very happy to hear that you 
are working to repeal the Affordable Care Act. I just got an up-close-
and-personal look at how dysfunctional it is while trying to shop for 
my own plan. It is hard enough to start a business in this country due 
to so many rules, regulations, and confounding taxes. This law makes it 
even harder. And I don't think the government should make me buy 
coverages I simply don't need. I know my situation, and I should be 
able to buy whatever I want without incurring four-figure tax 
penalties.
  Jason says to me: Dear Mike, I am a self-employed father of four 
feeling the hurtful effects of ObamaCare. For years there has been so 
much talk from Republicans about repealing ObamaCare. I am paying yet 
more money for less coverage. We are really feeling the effects of this 
in my family in our budget. My kids are going to bed hungry after 
dinner. We desperately need relief and now, not next year. I 
enthusiastically pulled the lever for Donald Trump and for you, and we 
are counting on you to make some real change in D.C. Please keep up the 
fight, and do it quickly.
  So this is not about Mike, it is not about John, it is not about any 
of us. What it is about is taking care of the people that we were sent 
here to represent. They are Republicans and they are Democrats, who 
some people could care less about any of us, but they expected us to do 
something for them. We are sitting here today because this law

[[Page H2429]]

is so bad. If it was so good, we wouldn't have to worry, but it is bad, 
with a capital B.
  Now, I have got to tell you, growing up, as a young kid, as it got 
toward Christmas--and I say this to my friends, by the way, on our 
side--I used to make a list right before Christmas. I put on that list 
everything I wanted. You know what, Mr. Speaker? Come Christmas 
morning, I never got everything I wanted, but I was so thankful for 
everything I got.
  We have to deliver today. We have to keep a promise today to the 
American people. We have to backtrack on a rookie mistake 7 years ago 
and make it better for the American people, not just for Republicans, 
not just for Democrats, not just for those who vote blue or red, but 
for those who expect us to do what we are supposed to do in the 
people's House. This is not the Republican House or the Democrat House, 
this is the people's House.
  Isn't it time for all of us to come together to get this done?
  We have a marvelous opportunity, but we could lose it. I ask you all 
and I urge you all to please vote for this act.
  Mr. NEAL. Mr. Speaker, I remind my colleague and my friend that with 
his vote for this bill, 41,400 people from his congressional district 
in Pennsylvania will lose their healthcare coverage.
  Mr. Speaker, I yield 2 minutes to the gentleman from Connecticut (Mr. 
Larson), who is from an adjacent district and a close friend and a 
long-time member of the Committee on Ways and Means and an individual 
who also contributed mightily to the development and writing of the 
Affordable Care Act.
  Mr. LARSON of Connecticut. Mr. Speaker, I associate myself with Mr. 
Neal's remarks, and especially him framing this issue from the outside 
about the arc of history.
  As we have witnessed in this Chamber time and again, dating back to 
Franklin Delano Roosevelt, when you look at the impact of 24 million 
people, you have to look at your colleagues on the other side of the 
aisle and say: Are you frozen in the ice of your indifference to what 
impacts the daily lives of people who have showed up at our forums and 
the forums that you have conducted?
  The sheer humanity of what is taking place across this country cries 
out for a solution. Yet all we have heard, as Mr. Neal said, is the 
helter-skelter back and forth of who is winning politically, what is 
happening with the Freedom Caucus, what is going to--if Trump loses, is 
Ryan out?
  The American people don't care about that. They care about their 
families. And this is the institution that we were sent to to work on 
their behalf. It is up to us to come together and work on behalf of the 
American people.
  This is not a healthcare bill. This is a tax bill. We are going to 
work on that later on, but we shouldn't start by saying that we are 
going to have a transfer of wealth in this Chamber from people who are 
begging and pleading and showing up at the townhalls and asking for our 
help, and our answer is a transfer of wealth in a tax bill. Everybody 
wants to know why we are taking this up first and not taxes. Because it 
is a tax bill, that is why.

                              {time}  1430

  Mr. BRADY of Texas. Mr. Speaker, I would remind my friend from 
Connecticut that 190,000 residents in Connecticut, two out of three 
eligible for ObamaCare, believed it failed them so badly they paid a 
tax or exempted themselves.
  Mr. Speaker, I yield 2 minutes to the gentlewoman from South Dakota 
(Mrs. Noem), who has weighed in in such a key way on health care.
  Mrs. NOEM. Mr. Speaker, it is no surprise that the Democrats today 
are upset, that they are complaining that they don't like this bill, 
because their number one goal all along, and I have heard them say it 
to me in conversations over the years, their number one goal was to go 
to a single-payer system. They wanted government-run health care, and 
we are on the track to that today.
  In fact, in my home State of South Dakota, at one time, we had 17 
options and companies that people could shop for their healthcare 
policies from. Today we have two.
  We are well down our road now to giving them exactly what they want. 
They hate this bill because it puts people back in control of their own 
health care. It doesn't let some bureaucrat in Washington, D.C., decide 
what treatment they can get in the future. It lets people decide that 
with their doctors.
  This is a vote, today, for freedom for people who have lived under 
the bureaucracy of the Federal Government not giving them options on 
how to take care of themselves and their families.
  Rising costs, shrinking options, increasing bureaucracy under 
ObamaCare has taken healthcare control away from patients, away from 
people, away from families struggling to pay their bills; and, against 
their best and own common sense and household budgets, they are forced 
to pay $10,000, $15,000, $20,000 more per year for health coverage, 
health coverage which has a deductible so high that they don't even 
utilize it then because they can no way meet the $6,500 deductible, 
$10,000 deductible, $12,000 deductible. So they don't even use it at 
all if they do have it. Their stories are reflected in all the data 
that we have seen.
  One hundred percent of the healthcare options on healthcare.gov in 
South Dakota have seen double-digit rate increases. Meanwhile, the 
number of providers families have to choose from has gotten much, much 
worse.
  We have a responsibility to eliminate ObamaCare's individual and 
employer mandates, which today's legislation does. It also abolishes 
the taxes that were included in ObamaCare, up to $1 trillion of taxes 
that were put on health care in order to pay for the bill, which will 
be eliminated as well.
  If left in place, the health insurance tax alone will raise costs on 
families up to $5,000 over the next decade.
  Bipartisan congressional Members have repeatedly opposed taxpayer 
funding of abortions, and that is fixed in this bill as well.
  When we talk about health care, we are talking about something very 
personal, which is why I want patients put back in control.
  Mr. NEAL. Mr. Speaker, I would remind my colleague that her vote for 
this bill will result in 63,000 people in South Dakota losing their 
healthcare coverage and care.
  Mr. Speaker, I yield 1 minute to the gentleman from Oregon (Mr. 
Blumenauer), a visionary, certainly, a forward-looking individual who 
also helped to write the ACA.
  Mr. BLUMENAUER. Mr. Speaker, it has come to this: considering 
hopelessly flawed legislation that the Republicans have had 7 years to 
prepare for and still couldn't do it right. It may still pass, but it 
is never going to be enacted because most people are figuring it out. 
They don't like it and they are being heard. That is why this bill has 
been stalled and the Republicans have been forced to twist the 
legislation in this fashion.
  But the bottom line remains: TrumpCare will cost more for people who 
need it the most. It will hurt older and lower-income people in order 
to create tax cuts for people who need them the least. TrumpCare will 
destabilize health insurance and will slowly but surely destroy 
Medicaid.
  It didn't have to be that way, but as long as people continue 
speaking out and fighting back with us, it won't be in the future, and 
we can have a new era in health care and in politics.
  With their help, it will be.
  Mr. BRADY of Texas. Mr. Speaker, I remind my dear friend from Oregon, 
153,000 Oregonians eligible for ObamaCare with generous subsidies said 
thank you, but no thank you.
  Mr. Speaker, I yield 2 minutes to the gentleman from South Carolina 
(Mr. Rice), my good friend and a key member of the Ways and Means 
Committee.
  Mr. RICE of South Carolina. Mr. Speaker, I stand in strong support of 
the American Health Care Act and urge my colleagues to vote in favor of 
the bill.
  ObamaCare was built on broken promises. President Obama said you 
could keep your policy, keep your doctor, and it would bring down the 
cost of the insurance for a family of four by $2,500 per year.
  It is time for the lies to stop. Let me share with Members the 
shameful reality of ObamaCare in South Carolina.
  It turns out you couldn't keep your doctor. In fact, the Medical 
University of South Carolina is not an accepted provider under 
ObamaCare in South Carolina. That is right. South Carolinians cannot go 
to the Medical University of South Carolina if they are

[[Page H2430]]

covered by ObamaCare exchange policies.
  It turns out you couldn't keep your policy. It is hard to believe, 
but more South Carolinians had their plans canceled by ObamaCare than 
have enrolled in the exchanges. 237,000 South Carolinians' policies 
were canceled in ObamaCare.

  It turns out South Carolinians did not see a $2,500 reduction in 
their healthcare premiums. In fact, premiums have increased by double 
digits every year since the exchange opened; and this year, premiums 
increased 28 percent and deductibles 26 percent.
  I submit to you that if you have a health insurance policy with 
$6,000 in deductibles and copays so high you can't afford to use your 
policy, regardless of the fact that statistics say you are covered, you 
are not covered.
  206,000 South Carolinians have signed up for ObamaCare--4 percent of 
the population. Ninety-six percent of South Carolinians are not on 
ObamaCare. Three times as many people in South Carolina have chosen to 
pay the mandate penalty rather than to pick up ObamaCare policies.
  Mr. Speaker, President Obama promised South Carolinians we would have 
many competitive plans to choose from, but after only 3 years of 
Obama's damage to our healthcare system, only one provider remains, and 
they are threatening to pull out.
  The SPEAKER pro tempore. The time of the gentleman has expired.
  Mr. BRADY of Texas. Mr. Speaker, I yield an additional 15 seconds to 
the gentleman from South Carolina.
  Mr. RICE of South Carolina. The CEO of a major hospital in South 
Carolina stated, the way it is going right now, it is probably going to 
implode in the next year or two. Our State's director of insurance, 
last year, said companies have given their best shot and can't sustain 
this business model, can't make a profit. The Affordable Care Act has 
not worked, does not work, and cannot work under this structure in 
South Carolina.
  Mr. NEAL. Mr. Speaker, I would remind my colleague that his vote for 
this bill will result in 70,000 people in his congressional district in 
South Carolina losing their healthcare coverage.
  Mr. Speaker, I now yield 1\1/2\ minutes to the gentleman from 
Wisconsin (Mr. Kind), who is a thoughtful member of the Ways and Means 
Committee and lucky enough to have been educated in the Commonwealth of 
Massachusetts.
  Mr. KIND. Mr. Speaker, we face a truly historic day today in the 
United States Congress. For the first time in our Nation's history, we 
have a Congress working with an administration offering the American 
people a healthcare reform bill that, instead of reducing the number of 
uninsured in this country, increases the uninsured by 24 million 
people, including 431,000 in my home State of Wisconsin.
  And we understand why. It is a simple explanation. This is a tax cut 
bill for the most wealthy in the guise of healthcare reform. That is 
unfortunate because it is a missed opportunity of fixing what isn't 
currently working in the healthcare system.
  If we wanted to be honest with the American people today, we would 
admit that there are important, good features of the Affordable Care 
Act that should remain and we should not end. But there are things that 
need to be fixed, and we have to stay focused on reducing healthcare 
costs for all Americans. Let's continue to work on delivery system 
reform and payment reform so we get better results at a better price.
  But a bill before us that increases the uninsured by 24 million, that 
delivers huge tax breaks to the most wealthy, that applies a new older 
American tax, especially in rural areas like mine in Wisconsin, and 
that robs money from the Medicare trust fund is not only a missed 
opportunity, it is bad legislation.
  I encourage my colleagues to vote ``no.'' We can do better. We must 
do better.
  Mr. BRADY of Texas. Mr. Speaker, I remind my good and thoughtful 
friend that 290,000 Wisconsinites that chose not to get ObamaCare were 
willing to pay a tax to stay out of a failed healthcare system.
  I am proud to yield 2 minutes to the gentlewoman from Indiana (Mrs. 
Walorski), a new member of our committee who is doing tremendous things 
in health care.
  Mrs. WALORSKI. Mr. Speaker, I rise today in strong support of the 
American Health Care Act.
  Yesterday marked 7 years since the ObamaCare law was signed into law. 
For 7 years, we have seen the same pattern: rising premiums, dwindling 
options, broken promises, and a collapsing system.
  In the State of Indiana, four insurers left the ObamaCare exchange 
just this year in the past 3 months, forcing 68,000 Hoosiers to shop 
for a new plan, making it even harder for them to choose and keep their 
doctor.
  But today we have the opportunity to repeal ObamaCare and replace it 
with a patient-centered system, lowering costs, increasing choices, and 
providing real protection.
  This legislation dismantles ObamaCare's burdensome taxes, mandates, 
and the job-killing medical device tax.
  It gives individuals and families access to quality, affordable 
health care through refundable tax credits and expanded health savings 
accounts.

  It provides resources for States to tailor solutions to the needs of 
their citizens, protecting women's health, addressing the opioid 
crisis.
  It gives States flexibility to implement innovative reforms.
  It allows my home State to continue building on its patient-centered 
Healthy Indiana Plan.
  It protects patients with preexisting conditions and ensures a stable 
transition so no one has the rug pulled out from underneath them.
  With the American Health Care Act, we are delivering on our promise 
and acting on the policies of President Trump. This bill is just the 
first step in a three-part effort to repair our Nation's healthcare 
system. Coupled with administrative actions and additional legislation, 
the AHCA will lower costs and build a marketplace with real choices 
instead of a one-size-fits-all plan.
  Mr. Speaker, 7 years of ObamaCare is long enough. Seven years of 
families seeing their premiums rise, plans canceled, and doctors 
dropped is enough. Today we can deliver on our promise and put our bold 
solutions into decisive action. The AHCA is a bill 7 years in the 
making. I urge my colleagues to join me in supporting it.
  Mr. NEAL. Mr. Speaker, I remind my colleague that her vote for this 
bill will result in 42,000 people in her congressional district in 
Indiana losing their healthcare coverage and care.
  I include in the Record a letter from Republican Governor Snyder of 
the State of Michigan raising his concerns about this legislation.

                                                State of Michigan,


                                             Executive Office,

                                      Lansing, MI, March 21, 2017.
     Hon. Sandy Levin,
     House of Representatives,
     Washington, DC.
       Dear Representative Levin: As Congress considers 
     legislation to repeal and replace the Affordable Care Act and 
     reform Medicaid, I want to ensure you are aware of the impact 
     that changes may have on beneficiaries in Michigan who rely 
     on these programs for access to care and overall health. I 
     also want to provide my perspective on priorities for federal 
     health reform and highlight how they have been utilized at 
     the state level to drive meaningful reform that has increased 
     access to cost-effective care.
       In its current form, the American Health Care Act (AHCA) 
     shifts significant financial risk and cost from the federal 
     government to states without providing sufficient flexibility 
     to manage this additional responsibility. The proposed 
     legislation reduces federal resources that our state relies 
     on to assist 2.4 million Michiganders enrolled in traditional 
     Medicaid and the Healthy Michigan Plan, our state's 
     innovative Medicaid expansion program.
       The current federal debate has largely focused on the 
     Medicaid expansion population, including over 650,000 
     childless adults and parents that are enrolled in the Healthy 
     Michigan Plan. However, half of all children in Michigan are 
     served by traditional Medicaid each year and roughly 67,000 
     of them currently reside in your district. Moreover, more 
     than 338,000 individuals with disabilities receive their 
     health care and support services through Medicaid and an 
     estimated 22,000 of these individuals reside in your 
     district. Altogether, there are 1.75 million children, 
     seniors, pregnant women and disabled individuals served by 
     traditional Medicaid in Michigan, and roughly 119,000 of them 
     reside in your district. As you know, these are our state's 
     most vulnerable citizens, friends and neighbors. The proposed 
     AHCA will adversely impact them.
       While reforming the nation's health care system is vital, 
     it is imperative that gains in health coverage and access to 
     care are maintained. These ideas are not mutually exclusive.

[[Page H2431]]

       In Michigan, innovative approaches to improving quality and 
     value are being utilized to support each individuals' 
     personal responsibility for their health. This has resulted 
     in significant reductions of nearly 50% in uncompensated 
     care, a dramatic decrease in the number of individuals using 
     the emergency room as a regular source of care, and nearly 
     85% of enrollees taking part in annual primary or preventive 
     care visits. As drafted, the AHCA would eliminate coverage 
     from the 49,000 individuals enrolled in the Healthy Michigan 
     Plan in your district, as Michigan taxpayers assume 
     responsibility over time for up to $800 million in additional 
     costs. This cost shift will trigger a provision in Michigan 
     law ending the Healthy Michigan program.
       I believe Medicaid reform is necessary, however, that 
     reform must be approached deliberately to ensure that state 
     flexibility and innovation are valued, Michigan providers 
     remain strong, and our most vulnerable citizens do not fall 
     through the cracks. Ideally, this would be done by removing 
     prescriptive program requirements that require states to seek 
     waivers when implementing innovative ideas. Instead, states 
     would be given performance based outcomes with federal 
     involvement only when performance is lacking.
       If Congress moves forward in passing the proposed AHCA, 
     which shifts financial risk to state taxpayers, my 
     administration and the Michigan Legislature must possess the 
     flexibility necessary to manage that risk. The Trump 
     Administration may provide additional flexibility to states, 
     however, I am concerned that federal agencies may encounter 
     limitations in federal statute. Ultimately, Michigan cannot 
     rely solely on the promise of future action without seeing 
     all of the tools that will be at our disposal to manage the 
     program.
       In addition, under the proposed AHCA, I remain concerned 
     about the affordability of insurance coverage in the 
     individual market. I am particularly concerned about the 
     impact this legislation may have on older Michiganders who 
     could see significant cost increases.
       I welcome the opportunity to partner with you to provide 
     greater federal budget predictability and improve health 
     outcomes of Michiganders, which in turn relieves pressure on 
     other social programs. I have worked with other Governors to 
     develop a proposal to accomplish these objectives while also 
     preserving coverage for Michiganders, and I hope this can 
     serve as a blueprint for you as we work together to 
     accomplish these goals.
       I look forward to continuing our partnership to help 
     Michiganders lead healthy and productive lives.
           Sincerely,
                                                      Rick Snyder,
                                                         Governor.

  Mr. NEAL. Mr. Speaker, I yield 2 minutes to the gentleman from New 
Jersey (Mr. Pascrell), who is a well-regarded member of the Ways and 
Means Committee. I think it is fair to say that everybody in this 
institution looks forward to his time when he gets up to speak.
  Mr. PASCRELL. Mr. Speaker, the question I get asked is: What the heck 
were they thinking about?
  Let me tell you what they are thinking about. Medicaid is the source 
of 25 percent of all projected public and private spending for drug 
abuse treatment. It is about $8 billion.
  Let's consider James Suber from my hometown of Paterson, New Jersey. 
Mr. Suber began seeking treatment when New Jersey expanded its Medicare 
program and provided more comprehensive access to treatment.
  At least New Jersey got it half right.
  Each morning Mr. Suber receives treatment at Paterson Counseling 
Center, which allows him to go to work as a cleaner at Well of Hope, 
another treatment center in Paterson serving the homeless.
  Without the treatment he receives through Medicaid, he wouldn't be 
working. He would be using the emergency department at St. Joseph's 
hospital, the most expensive part of the hospital. Or maybe he wouldn't 
have survived.
  So, Mr. Speaker, for the life of me, I don't understand why we would 
jeopardize treatment for James and the millions of other Americans 
facing similar challenges. What were they thinking?
  Will this bill improve Medicaid? Nope.
  Will this bill increase the number of Americans with health coverage? 
Nope.
  Will it lower costs on the exchanges? Nope.
  Will this bill bolster employer coverage? No.
  Will coverage now provide more access to care, a promise time and 
time again by Mr. Trump, himself? No.
  Will it strengthen Medicare? No.

                              {time}  1445

  Mr. Speaker, it is obvious. We know we are trying to change things 
and make them better.
  We changed Medicare. We did it together.
  We changed Medicaid. We did it together.
  We changed a lot of things together, but you chose the only lonely 
path.
  Mr. BRADY of Texas. Mr. Speaker, I remind my good friend from New 
Jersey that 314,000 residents of New Jersey said ``no thank you'' to 
ObamaCare because it failed them.
  I yield 2 minutes to the gentleman from Michigan (Mr. Bishop), a new 
member of the committee, who dove into this issue with great thoughtful 
and conscientious work.
  Mr. BISHOP of Michigan. Mr. Speaker, I rise today in support of the 
American Health Care Act, and I want to thank the chairman for his 
leadership on this measure.
  Mr. Speaker, I came to Washington, D.C., to make a difference. When 
it comes to health care, it is readily apparent that ObamaCare does not 
work for most Americans. We know for a fact, as we are standing here 
today, that the current system is collapsing upon itself.
  Our Nation has endured 7 long years of this mess, and today we have 
the obligation and the responsibility to act. I have heard many critics 
of this proposal, but I was raised to do what is right, to be a part of 
the solution, and not sit idly by on my hands as a spectator and watch 
Rome burn.
  I came to Congress to make a difference, to find solutions to the 
many issues that vex our country. I came here to reduce the size and 
scope of an unwieldy government, to get government out of the way of 
everyday citizens. I came here to address spending, a $20 trillion debt 
in this country, to bring back free-market principles. I came here to 
defend the Constitution and our founding principles, and turn power 
back to the States and to the people.
  All that said, every single one of these principles can be found in 
this bill. The American Health Care Act reduces spending and cuts the 
taxes that have strangled businesses and individuals for the last 7 
years. It represents the first real entitlement reform in the 52-year 
history of Medicaid. It deletes Federal mandates that rob citizens of 
their individual liberty.
  Mr. Speaker, this bill may not be perfect, but it is a dramatic step 
in the right direction. And before I am lectured as to unsubstantiated 
facts and fear tactics as to how this is going to impact my State, I 
would suggest to you that 420,000 Michiganders eligible for Medicare 
said ``thanks, but no thanks'' to the broken promise of affordable 
health care.
  And that is why, Mr. Speaker, I am going to vote for this bill, and I 
would ask my colleagues to support it.
  Mr. NEAL. Mr. Speaker, I would remind my colleague that his vote for 
this bill will result in 38,200 people from his congressional district 
in Michigan losing their healthcare coverage, and 313,123 people in the 
State of Michigan, indeed, did sign up for the Affordable Care Act.
  Mr. Speaker, I yield 2 minutes to the gentleman from New York (Mr. 
Crowley), a long-time friend, a very sound member of the committee, and 
also the well-regarded chairman of the Democratic Caucus.
  Mr. CROWLEY. Mr. Speaker, this bill is a bad policy built on horrible 
process. Twenty-four million Americans will lose their coverage if this 
bill becomes law. Premiums and out-of-pocket expenses will skyrocket, 
especially for older Americans because of the age tax, as hardworking 
Americans are forced to subsidize tax cuts for the wealthy.
  It is no wonder this bill was crafted in the dead of night behind 
closed doors. It is so bad, even Members of the Republican Party are 
rejecting this bill, but President Trump and Republican leadership 
insisted they need to repeal ObamaCare at any cost, even if the price 
will be making health care out of reach for veterans, for seniors, and 
many of the hardest-working Americans.
  So the majority made it worse, and then they made it worse again. Now 
they have taken away the bare minimum requirements for insurance like 
covering emergency room visits or prescription drugs. It will crush any 
protections for preexisting conditions.

[[Page H2432]]

There is no guarantee the treatment you need for your condition will 
even be covered under this bill. Image that: healthcare coverage that 
doesn't cover your health. Insurance that insures absolutely no peace 
of mind for what life may bring you.
  This body blow to critical health protections was done just to win 
votes, like so many of the other provisions and political favors, like 
the Empire State kickback, the Buffalo bribe, and the Syracuse sellout. 
I call it simply a political ploy.
  That provision, which will cut $2 billion from only New York State, 
has been blasted by newspapers from The Buffalo News to Newsday on Long 
Island. They have called it a train wreck. They have called it bloody 
money. Like everything else in this bill, it represents the worst kind 
of backroom, shady maneuvering.
  This bill is bad for New York, bad for the democratic system, and bad 
for America. My colleagues on the other side of the aisle should be 
ashamed of themselves. I know many of you are. But this bill is 
appalling, and I urge everyone in this Chamber to vote it down. And, 
Mr. Chairman, I know that 2.7 million New Yorkers will lose their 
health care if this bill becomes law.
  Mr. BRADY of Texas. I remind my friend from New York, nearly four out 
of five New Yorkers said no to ObamaCare because it failed them.
  Mr. Speaker, I yield 1 minute to the gentleman from Iowa (Mr. King), 
my dear friend.
  Mr. KING of Iowa. Mr. Speaker, I want to thank the chairman for 
yielding to me.
  Seven years ago today, I brought the first repeal of ObamaCare here 
to this Congress. Forty words, to rip it out by the roots as if such 
act had never been enacted. I would like to be here today passing the 
full repeal of ObamaCare. We are not, but this is the first bite at the 
repeal apple in a process to hopefully get all of this thing done in 
one day.

  If I thought we could do it all in one bite, I would stand for that, 
but instead, here is what we have got. We have got a $1 trillion tax 
cut. We have got a $1.15 trillion spending cut. We have got a $150 
billion deficit reduction. We have got a bill that eliminates the 
employer mandate, eliminates the individual mandate, and it eliminates 
Federal mandates in the essential health benefits package of those 10 
mandates--that I despise, by the way.
  It expands health savings accounts--doubles them--it allows for us to 
pass selling insurance across State lines, and it enables catastrophic 
health insurance. That is a pretty good list, and that is the list of 
things that I am going to support here when this goes up for a vote.
  Mr. Speaker, I urge its adoption.
  Mr. NEAL. Mr. Speaker, I remind my colleague that his vote for this 
bill will result in 40,900 people from his congressional district in 
Iowa losing healthcare coverage. I also want to thank the gentleman for 
being the first speaker on the Republican side to acknowledge that this 
is a tax cut.
  Mr. Speaker, I yield 1 minute to the gentleman from Chicago, Illinois 
(Mr. Danny K. Davis), a distinguished member of the Ways and Means 
Committee and my friend.
  Mr. DANNY K. DAVIS of Illinois. Mr. Speaker, I rise in strong 
opposition to this draconian, Dracula-inspired health bill. It is not 
really a health bill at all. As a matter of fact, it is a tax cut for 
the wealthiest individuals in our country. This bill will decimate all 
of the public health gains that professional health personnel and 
activists have fought for the last 50 years.
  This bill will take out the opportunity for those low- and moderate-
income individuals who fall between the gap created by Medicaid and 
nothing. They are the least of those in our society. And when you take 
away health care for that group of individuals, history will not regard 
you well.
  I believe that the best way to measure the effectiveness of a society 
is by how well it treats its young, how well it treats its old, and how 
well it treats those who have difficulty caring for themselves.
  I will vote ``no.'' I urge us all to do so.
  Mr. BRADY of Texas. Mr. Speaker, I remind my good friend from 
Illinois, half a million Illinoisans have said no to ObamaCare because 
it failed them.
  Mr. Speaker, I reserve the balance of my time.
  Mr. NEAL. Mr. Speaker, I yield 2 minutes to the gentlewoman from 
California (Ms. Sanchez), the vice chair of the Democratic Caucus, and 
a very strong performer on the Ways and Means Committee.
  Ms. SANCHEZ. Mr. Speaker, I rise today in opposition to the 
Republican's so-called healthcare bill.
  It pains me to even call it a healthcare bill because it is actually 
a massive tax cut for insurance CEOs that provides nearly zero 
healthcare benefits for the American people.
  In fact, TrumpCare ensures that 24 million Americans will lose their 
health insurance coverage. Seniors will be charged more, and insurance 
companies will once again dictate the health of the American people. On 
the very day that the majority tax cuts for the rich come into effect, 
on January 1, 2018, at least 40,000 of my own constituents would 
immediately lose their health care.
  But that is not all. The Republican idea of health coverage will 
leave millions of Americans without the basic health services that they 
expect and that they deserve. That means that the monthly premium you 
pay won't cover all of the services you will need to get better if you 
get sick. The Republican healthcare plan won't cover your emergency 
room visit, the X-rays, or even the prescription drugs you need to 
recover.
  Heaven forbid if you need prenatal or pediatric care, too. Basically, 
under this plan, one illness is enough to bankrupt a family for a 
lifetime. If you asked anyone on the street, no one in America would 
call this health insurance. Yet, my Republican colleagues hail this as 
choice--the choice to go bankrupt if you get sick or, God forbid, have 
an accident.
  So, Mr. Speaker, I have to ask: How many Republicans are left who 
actually support the bill? Who wants to kick thousands of people off of 
Medicaid, reduce care for the disabled, and strip children of their 
health care because that is exactly what you are going to do if you 
vote for this bill. It does the exact opposite of what you, your party, 
and President Trump have promised the American people.
  This bill doesn't provide better, cheaper health care for everyone. 
And guess what? Everybody knows that. By voting for this bill, you will 
literally force millions of Americans to pay more for less and 
jeopardize the health of our country for generations.
  So if you vote to break all of the promises you made to the American 
people, then you are going to own it, and you are going to be 
responsible for whatever happens. Vote down this bill.

  Mr. BRADY of Texas. Mr. Speaker, I reserve the balance of my time.
  Mr. NEAL. Mr. Speaker, I yield 1 minute to the gentlewoman from 
Alabama (Ms. Sewell), a valued member of the Ways and Means Committee.
  Ms. SEWELL of Alabama. Mr. Speaker, for 7 years, our Republican 
colleagues have railed against the Affordable Care Act, but is this the 
best they can offer now: TrumpCare? The Republican bill, TrumpCare, is 
a bad deal for Americans, and it is a bad deal for Alabamians.
  By every matrix, cost, coverage, and care, it is a bad deal. On cost, 
TrumpCare will cost more and give us less. For Alabama hospitals, 
TrumpCare will mean a $97 million increase in uncompensated cost care, 
and it is an age tax for seniors. Seniors will pay five times more than 
the young for their health insurance.
  On coverage, TrumpCare will mean 24 million Americans and 243,000 
Alabamians will lose their healthcare coverage. On quality of care, 
TrumpCare will mean that essential benefits will be lost: essential 
benefits like rehabilitative care, mental health, and preventive 
services.
  Mr. Speaker, what is clear, TrumpCare is not a healthcare bill. It is 
a tax-cut-for-the-wealthy bill--$600 billion in tax cuts. So I say to 
you, my Republican colleagues know what they are against, the 
Affordable Care Act. But what are they for? What are they for? I ask 
all of you.
  Mr. BRADY of Texas. Mr. Speaker, I reserve the balance of my time.
  Mr. NEAL. Mr. Speaker, might I inquire as to how much time remains?
  The SPEAKER pro tempore. The gentleman from Massachusetts has 5\3/4\

[[Page H2433]]

minutes remaining under this committee time allocation.
  Mr. NEAL. Mr. Speaker, I yield 1 minute to the gentlewoman from 
California (Ms. Chu), a new member on the Ways and Means Committee, and 
a very thoughtful Member of Congress.

                              {time}  1500

  Ms. JUDY CHU of California. Mr. Speaker, my constituent Patty never 
had to worry about health care. Her husband had insurance through his 
job. But last year, Patty's husband passed away suddenly. Overnight, 
Patty found herself without health coverage for herself and her 20-
year-old son, who had a preexisting condition.
  Even though she was grieving over the sudden loss of her husband, 
Patty couldn't afford COBRA and had less than a month to find health 
care for her family. Thank goodness she was able to get coverage 
through the ACA.
  Under TrumpCare, Patty could have her life upended all over again. 
Patty is 62 years old, and TrumpCare would cause premiums for people 
over 60 to increase by more than $6,000 a year, making insurance 
unaffordable. And under the age tax created in this bill, insurance 
companies could charge Patty five times as much as a young person. She 
could see skyrocketing costs for her hypertension and doctor's visits.
  TrumpCare is a bad deal for Americans like Patty.
  Mr. Speaker, I urge my colleagues to vote a resounding ``no'' to this 
downright cruel bill.
  Mr. BRADY of Texas. Mr. Speaker, I reserve the balance of my time.
  Mr. NEAL. Mr. Speaker, I yield 1 minute to the gentleman from Oregon 
(Mr. DeFazio).
  Mr. DeFAZIO. Mr. Speaker, this so-called health bill is actually just 
mostly targeted for tax cuts for the wealthiest among us.
  Let's look at it this way: a millionaire will get a $30,000-a-year 
tax cut. A 64-year-old senior who earns $30,000 a year--that is all he 
earns, just the tax cut the millionaire gets--they will see their 
premium go from $1,700 a year, to $15,000 a year. That is half their 
income.
  They are going to have a choice: give up their house so they can buy 
health insurance or don't buy health insurance, pray you don't have a 
health emergency, and go bankrupt or die. Those are great choices.
  This says a lot about the values of the Republican leadership and 
their obsession. Instead of fixing the problems with the Affordable 
Care Act, they want to kill it. It says a lot about their values. They 
are pathetic.
  Mr. BRADY of Texas. Mr. Speaker, I reserve the balance of my time.
  Mr. NEAL. Mr. Speaker, I yield 1 minute to the gentleman from Arizona 
(Mr. O'Halleran).
  Mr. O'HALLERAN. Mr. Speaker, I rise in strong opposition to the so-
called American Health Care Act. I am alarmed at the real consequences 
this bill will have on rural Arizona and rural America.
  These communities will be disproportionately harmed by this bill. In 
Coconino County, a 40-year-old making $30,000 a year will go from a 
$2,400 payment to a $6,000 payment.
  Getting away from my script for a second, I spent many years on the 
west side of Chicago looking at what the core side of poverty looks 
like night after night, family after family, in our cities and our 
towns in this wonderful America. I know a little bit about math, and I 
know that 20 million people insured is better than 24 million people 
uninsured.
  Please vote ``no.''
  Mr. BRADY of Texas. Mr. Speaker, I reserve the balance of my time.
  Mr. NEAL. Mr. Speaker, I yield 30 seconds to the gentleman from 
Tennessee (Mr. Cohen).
  Mr. COHEN. Mr. Speaker, this is not a healthcare bill. This is a 
wealth care bill.
  Unfortunately, President Trump, when he spoke in Louisville, said we 
had to pass this bill to get the big tax cuts. It is about wealth care. 
It is the Ebenezer Scrooge law of this Congress.
  The insurance you will get with the amendments made will be as 
worthless as the degree from Trump University. We do not need wealth 
care, but we need health care.
  Mr. BRADY of Texas. Mr. Speaker, I reserve the balance of my time.
  Mr. NEAL. Mr. Speaker, I yield myself the balance of my time.
  In closing, I want to make sure the people of America understand what 
we are doing here in about 1 hour. We heard during the course of a 
Presidential campaign the promise that everything was going to be 
covered and we would be tired of winning.
  If winning means that 24 million Americans are going to lose their 
healthcare coverage, if winning means imposing an age tax on seniors, 
if winning means higher out-of-pocket costs for working Americans, and 
if winning means robbing $75 billion from the Medicare trust fund, we 
don't want to be part of that victory lap.
  This isn't about one person making up alternative facts. Our 
statements today have been based upon the CBO, the National Rural 
Health Association, the American Medical Association, the American 
Association of Retired Persons, and the March of Dimes.
  This bill has fewer covered, weaker protections, and higher costs. 
Let's call this what it is today; it is a $1 trillion tax cut for the 
richest amongst us.
  The Republicans are now facing the art of the ordeal. They have a bad 
plan, and they know it. They have scrambled for the last week to try to 
figure out how to stitch it together, and it hasn't worked.
  For those across this country, think of the following: no maternity 
care, fewer hospital visits, no mental health services for those 
families who are struggling with a family member who has an opiate 
addiction, which is the crisis of our time.
  This is more of the same: tax cuts for the wealthiest amongst us and 
healthcare cuts for everyone else.
  Mr. Speaker, I reserve the balance of my time.


 =========================== NOTE =========================== 

  
  March 24, 2017, on page H2433, the following appeared: Mr. 
Speaker, I yield back the balance
  
  The online version has been corrected to read: Mr. Speaker, I 
reserve the balance


 ========================= END NOTE ========================= 

  Mr. BRADY of Texas. Mr. Speaker, I yield myself the balance of my 
time to close.
  Mr. Speaker, do you want to know how bad ObamaCare is?
  Twice as many Americans have exempted themselves, have paid a fine, 
or found another way out of ObamaCare for everyone who took it.
  I am a conservative, and I am proud of the conservative win in this 
bill. I am proud of the $1 trillion in tax relief on our small 
businesses, our patients, and our families. I am proud of the more than 
$1 trillion of spending cuts that Washington cannot afford nor sustain. 
I am proud of the first reforms in Medicaid since the program was 
created in giving States back control of that plan, including the 
option of a work requirement.
  I am proud to repeal ObamaCare mandates that have forced Americans 
into health care they can't afford and don't want. I am proud to defund 
Planned Parenthood once and for all. And I am proud of the $150 billion 
of deficit reduction.
  This is a clear choice, and we will stand where we stand today: the 
choice between President Trump and more freedom or ObamaCare and less 
freedom. I stand with President Trump.
  Mr. Speaker, I yield back the balance of my time.
  Mrs. BLACK. Mr. Speaker, I yield myself such time as I may consume.
  I include in the Record a letter dated March 7, 2017, from Dr. Thomas 
Price, the Secretary of Health and Human Services, who sent a letter of 
support for the American Health Care Act to Chairmen Walden and Brady.

                                                  The Secretary of


                                    Health and Human Services,

                                    Washington, DC, March 7, 2017.
     Hon. Greg Walden,
     Chairman, Committee on Energy & Commerce,
     Washington, DC.
     Hon. Kevin Brady,
     Chairman, Committee on Ways & Means,
     Washington, DC.
       Dear Chairman Walden and Chairman Brady: On behalf of the 
     Trump Administration, I am writing in support of the 
     reconciliation recommendations recently released for 
     consideration by your Committees. Together, they align with 
     the President's goal of rescuing Americans from the failures 
     of the Affordable Care Act. These proposals offer patient-
     centered solutions that will provide all Americans with 
     access to affordable, quality healthcare, promote innovation, 
     and offer peace of mind for those with pre-existing 
     conditions.
       Your legislative proposals are consistent with the 
     President's commitment to repeal the Affordable Care Act; 
     provide advanceable, refundable tax credits for Americans who 
     do not already receive such tax benefits through health 
     insurance offered by their employers; put Medicaid on a 
     sustainable path and remove burdensome requirements in the 
     program to better target

[[Page H2434]]

     resources to those most in need; empower patients and put 
     healthcare dollars and decisions back into their hands by 
     expanding the use of health savings accounts; ensure a stable 
     transition away from the Affordable Care Act; and protect 
     people with pre-existing conditions.
       Achieving all of the President's goals to reform healthcare 
     will require more than what is possible in a budget 
     reconciliation bill, as procedural rules on this type of 
     legislation prevent inclusion of key policies such as selling 
     insurance across state lines, lowering drug costs for 
     patients, providing additional flexibility in Medicaid for 
     states to manage their programs in a way that best serves 
     their most vulnerable citizens, or medical legal reforms. 
     Your proposals represent a necessary and important first step 
     toward fulfilling our promises to the American people. We 
     look forward to working with you throughout the legislative 
     process, making necessary technical and appropriate changes, 
     and ensuring eventual arrival of this important bill on the 
     President's desk.
           Yours truly,
                                            Thomas E. Price, M.D.,
                                                        Secretary.

  Mrs. BLACK. Mr. Speaker, I include in the Record a letter that comes 
from 24 of our Governors in support of the repeal of ObamaCare, and I 
would like to read just two quick paragraphs out of the letter:
  ``We support efforts to Reform the system.
  ``To provide access to affordable and quality health care, we must 
reform the system. We support a plan that gives state governments 
maximum flexibility to reform Medicaid and the system surrounding it. 
The states are more effective, more efficient and more accountable to 
the people. What works in one state may not work in another location, 
and true reform will allow states to recognize and meet the unique 
needs of the people all across America.
  ``We recognize that a vote in the House of Representatives is the 
first step in the Repeal, Replace and Reform process. The members of 
the United States Senate will undoubtedly make additional improvements 
before final approval by the President. We also recognize that the 
Secretary of Health and Human Services is committed to working with 
state leaders to provide maximum flexibility for true reform.''

                                                   March 24, 2017.
     Hon. Mitch McConnell,
     Majority Leader, U.S. Senate,
     Washington, DC.
     Hon. Paul D. Ryan,
     Speaker, House of Representatives,
     Washington, DC.
       Dear Leader McConnell and Speaker Ryan:  Thank you for your 
     service to our country. Please allow us to offer our thoughts 
     about the pending vote on the American Health Care Act. 
     Americans want personalized, patient-centered healthcare that 
     treats them as individuals not a statistic, and that demands 
     we repeal Obamacare, replace it, and reform the system.


                   We support the Repeal of Obamacare

       Obamacare is collapsing. If we do nothing, people will lose 
     access to health care coverage. As it stands now, one-third 
     of the counties nationwide have only a single insurance 
     carrier. Americans in these areas have essentially no 
     choices, while they watch their premiums rise dramatically. 
     The Congressional Budget Office estimates that 28 million 
     Americans will lose coverage over the next decade if changes 
     are not made to the Affordable Care Act.
       As the Affordable Care Act continues to deteriorate, and as 
     insurance premiums skyrocket across the nation, opposition to 
     this failed policy grows. Governor Mark Dayton (D-MN) said, 
     ``the Affordable Care Act is no longer affordable.'' 
     Similarly, Bill Clinton called ObamaCare, ``. . . the 
     craziest thing in the world.'', adding that people ``wind up 
     with their premiums doubled and their coverage cut in half.'' 
     The President and Congress must act now to repeal the 
     Affordable Care Act to protect the citizens we serve in the 
     states.


                We support efforts to Replace Obamacare

       Most Americans receive their health insurance coverage 
     through their employer or through Medicare. These individuals 
     will not see a direct change from the repeal of Obamacare. 
     For those Americans who do not receive coverage through their 
     employer, Medicare or Medicaid, we support a refundable tax 
     credit they can use to obtain affordable health care coverage 
     within the marketplace.


                We support efforts to Reform the system

       To provide access to affordable and quality health care, we 
     must reform the system. We support a plan that gives state 
     governments maximum flexibility to reform Medicaid and the 
     system surrounding it. The states are more effective, more 
     efficient and more accountable to the people. What works in 
     one state may not work in another location, and true reform 
     will allow states to recognize and meet the unique needs of 
     people all across America.
       We recognize that a vote in the House of Representatives is 
     the first step in the Repeal, Replace and Reform process. The 
     members of the United States Senate will undoubtedly make 
     additional improvements before final approval by the 
     President. We also recognize that the Secretary of Health and 
     Human Services is committed to working with state leaders to 
     provide maximum flexibility for true reform.
       Governors are pleased to have an administration and a 
     Congress willing to collaborate with the states to address 
     the legitimate needs of our people. We have compassion for 
     those concerned about the uncertainty surrounding the 
     changes. This is why it is imperative that the Congress act 
     quickly on Repeal, Replace and Reform.
       This is a multi-stage process. There is much more work to 
     be done, and process can only begin with a vote in the House 
     of Representatives. With this in mind, we humbly request that 
     you vote to repeal and replace Obamacare and to reform the 
     system going forward. Thank you.
           Sincerely,
       Governor Scott Walker, Wisconsin; Governor Robert Bentley, 
     Alabama; Governor Rick Scott, Florida; Governor C.L. 
     ``Butch'' Otter, Idaho; Governor Eric Holcomb, Indiana; 
     Governor Terry E. Branstad, Iowa; Governor Sam Brownback, 
     Kansas; Governor Matt Bevin, Kentucky; Governor Paul R. 
     LePage, Maine; Governor Phil Bryant, Mississippi; Governor 
     Eric R. Greitens, Missouri; Governor Pete Ricketts, Nebraska; 
     Governor Christopher T. Sununu, New Hampshire; Governor Doug 
     Burgum, North Dakota; Governor Ralph Torres, Northern Mariana 
     Islands; Governor Mary Fallin, Oklahoma; Governor Henry 
     McMaster, South Carolina; Governor Dennis Daugaard, South 
     Dakota; Governor Bill Haslam, Tennessee; Governor Gary R. 
     Herbert, Utah; Governor Matthew H. Mead, Wyoming.

  Mrs. BLACK. Mr. Speaker, I include in the Record a list of groups 
supportive of the American Health Care Act. We have many groups, from 
conservative groups to pro-life groups, to industry groups; and among 
those would be several insurance providers, such as Blue Cross Blue 
Shield, Anthem, and others.

           Groups Supportive of the American Health Care Act


                             conservatives

       American Legislative Exchange Council
       Americans for Tax Reform
       Association of Mature American Citizens
       Center of the American Experiment
       Citizens Against Government Waste
       Independent Women's Voice
       Institute for Liberty
       Log Cabin Republicans
       Market Institute
       National Taxpayers Union--Key Vote
       Obamacare Repeal Coalition
       Six Degrees Project
       Small Business & Entrepreneurship Council
       Taxpayers Protection Alliance


                            Pro-life groups

       American Center for Law and Justice
       Catholic Medical Association
       Concerned Women for America
       Faith & Freedom Coalition--Key Vote
       National Right to Life--Key Vote
       Susan B. Anthony List


                                Industry

       Advanced Medical Technology Association (AdvaMed)
       America's Health Insurance Plans (AHIP)
       American Benefits Council
       American Builders and Contractors
       American College of Cardiology
       American Supply Association
       Anthem Insurance
       Associated General Contractors of America--Key Vote
       Blue Cross Blue Shield
       Consumer Healthcare Products Association
       Corporate Health Care Coalition
       Employers Council on Flexible Compensation
       ERISA Industry Committee (ERIC)
       Food Marketing Institute
       Health Leadership Council
       HSA Council
       International Franchise Association (IFA)
       Medical Device Manufacturers Association (MDMA)
       National Association of Manufacturers (NAM)
       National Association of Wholesale Distributers (NAW)--Key 
     Vote
       National Business Group on Health
       National Club Association
       National Council of Chain Restaurants
       National Federation of Independent Businesses--Key Vote
       National Grocers Association
       National Restaurants Association
       National Retail Federation--Key Vote
       National Roofing Contractors Association
       One Nation Health
       Self-Insurance Institute of America, Inc.
       The Association of Chief Human Resource Officers (HR 
     Policy)
       US Chamber of Commerce--Key Vote

  Mrs. BLACK. Mr. Speaker, I yield 2 minutes to the gentleman from 
Texas (Mr. Hensarling), the chair of the Financial Services Committee.
  Mr. HENSARLING. Mr. Speaker, tragically, I receive correspondence 
every week like this. I heard from Rita in east Texas, who writes me:

       Since ObamaCare took effect, my insurance no longer covers 
     my colonoscopies as

[[Page H2435]]

     preventative care. I now pay $1,000 and more out of pocket 
     versus $100 outpatient fee.

  I heard from Frances in the Dallas area near where I live. A few 
years ago she was tragically diagnosed with tonsil cancer. The good 
news is she had a good policy; $600-a-month premium and a maximum out 
of pocket of $3,500. But thanks to ObamaCare, her insurance company 
dropped her twice, and she wrote:

       They dropped me again because they are leaving the Dallas 
     market.

  Her premiums and deductibles doubled. She lost her oncologist, and 
she writes that this is all because of ObamaCare, the Affordable Care 
Act.
  I heard from Tonya in Van Zandt County, in my district:

       We had five family members covered by insurance at around 
     $800 a month until ObamaCare. Our insurance premiums 
     skyrocketed to $1,500 a month, equivalent to a house payment, 
     with a $15,000 deductible, and we cannot see the doctors that 
     know our medical history. Repeal it. I should not be forced 
     to pay for something I cannot use. This has been a nightmare.

  Mr. Speaker, ObamaCare has been a nightmare. It is collapsing as we 
speak. People are losing their coverages. Insurance plans are pulling 
out of States and counties. Tens of millions of our fellow countrymen 
have been forced to buy health insurance plans they cannot afford, they 
do not want, and that do not work for them.
  Right here, right now, we have a choice: failed ObamaCare or the 
American Health Care Act that begins the process of providing Americans 
with guaranteed access to quality, affordable, patient-centered health 
care.
  It clearly advances the cause of freedom, and all Members should 
support it and end the nightmare of ObamaCare.
  Mr. SCOTT of Virginia. Mr. Speaker, I ask unanimous consent that I be 
allowed to manage the balance of the time remaining.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from Virginia?
  There was no objection.
  Mr. SCOTT of Virginia. Mr. Speaker, I yield myself such time as I may 
consume.
  Mr. Speaker, as we talk about the Affordable Care Act, I think it is 
important to remind ourselves of the situation before it passed: costs 
were going through the roof, those with preexisting conditions could 
not get insurance, women were paying more than men, and every year 
millions of people were losing their insurance.
  We passed the Affordable Care Act. Since then, the costs have 
continued to go up, but at the lowest rate in 50 years. Those with 
preexisting conditions can get insurance at the standard rate. Women 
are no longer paying more than men. Instead of millions of people 
losing their insurance every year, more than 20 million more people now 
have insurance.
  The full name of the Affordable Care Act is the Patient Protection 
and Affordable Care Act.
  Now your coverage can't be canceled if your insurance company decides 
that it has paid too much. Preventive services, such as cancer 
screenings, are free with no copays and deductibles. We are closing the 
doughnut hole. Those under 26 can stay on their parents' policies.
  We also funded community health centers, made investments in 
education to produce more doctors, nurses, and other professionals. 
Through all of that, the Medicare trust fund is more solvent than it 
was before.
  Still, the law is not perfect. But if we are going to make any 
changes, we ought to improve the law, not make it worse.
  Incredibly this bill makes it worse. Now, the CBO has separated 
promises and press releases from reality. Twenty-four million fewer 
people will have insurance, and the Republicans call this choice in 
freedom to be uninsured. Most everybody else will pay more and get 
fewer benefits. All of those consequences will occur if the proposal 
actually works.

                              {time}  1515

  A number of States have done what this bill tries to do, and that is 
cover people with preexisting conditions without universal coverage. 
All of those attempts failed.
  So the question we must ask is: Who will be better off if this bill 
passes? Certainly not older people who will face the bill's age tax. 
Certainly not veterans who will lose benefits. Certainly not senior 
citizens in nursing homes and people with disabilities because Medicaid 
is cut. Even the solvency of the Medicare trust fund will be worse.
  But millionaires will get tax cuts.
  Mr. Speaker, we have been hearing a lot of complaints and 
shortcomings about the Affordable Care Act, but if we are going to make 
any changes, we should improve it. Unfortunately, this bill makes 
things worse: 24 million will lose their insurance, most everybody else 
will pay more and get less. This bill should be defeated.
  Mr. Speaker, I reserve the balance of my time.
  Mrs. BLACK. Mr. Speaker, it is now my honor to yield 2 minutes to the 
gentleman from Virginia (Mr. Goodlatte), the distinguished chairman of 
the Judiciary Committee.
  Mr. GOODLATTE. Mr. Speaker, I want to tell you why I am supporting 
this legislation, the American Health Care Act.
  Kaye, from Roanoke, contacted me about President Obama's promise that 
she could keep her health care. She shared that she received a letter 
from her insurer stating that her policy was going to increase by $600 
per month--increase by $600 per month. Since she wasn't of age to be on 
Medicare but wasn't working because she was at home caring for her sick 
husband, she was frustrated with her situation.
  Kaye couldn't afford the extra money she owed on top of the bills for 
her husband's medical treatment. She told me: ``So I will now have to 
pay the fine, drop my insurance, and hope I do not get sick.''
  I told Kay I would vote to repeal and replace ObamaCare.
  A nurse from Warren County wrote to me: ``The care that I give my 
patients is founded on their ability to choose their course of care. We 
advocate every day for our patients to have more choices in their care, 
and it will be very painful for us to deny them those options and to 
deny them care.'' She asked me to stand against ObamaCare, and I told 
her I would.
  Susan, from Bedford County, told me her health insurance premium 
increased 156 percent and her deductible increased 766 percent in just 
2 years. She asked how we could make her pay such high rates. I told 
Susan I would vote to repeal ObamaCare.
  Mr. Speaker, I told my constituents that I would stand for them to 
repeal this law that has hurt their ability to get the affordable care 
they want and need. Passing the American Health Care Act is the first 
step in repealing ObamaCare and replacing it with solutions that put 
patients first. I urge my fellow Members to support this bill.
  ObamaCare has failed far too many in the Sixth District of Virginia. 
The status quo cannot continue.
  Mr. SCOTT of Virginia. Mr. Speaker, I remind my distinguished 
colleague from Virginia that his vote for this bill will result in 
56,100 more people from his congressional district in Virginia losing 
health care.
  Mr. Speaker, I yield 1 minute to the gentleman from the Mariana 
Islands (Mr. Sablan).
  Mr. SABLAN. Mr. Speaker, I oppose the American Health Care Act 
because it fails to increase coverage for 3.8 million Americans in the 
insular areas: American Samoa, Guam, the U.S. Virgin Islands, Puerto 
Rico, and my own district, the Mariana Islands.
  President Trump promised, ``Everybody's going to be taken care of 
much better than they're taken care of now,'' but that is not 
happening. Instead of taking the opportunity to take care of all 
Americans, the American Health Care Act ignores the insular areas:
  We are not included in the new Medicaid per capita funding proposal. 
As a matter of fact, in a year, we would see our Medicare funding 
reduced by 68 percent.
  We are not included in the new Patient and State Stability Fund. And 
the new tax credit for insurance premiums is actually a new cost, an 
unfunded Federal mandate, imposed by Congress on territorial 
governments.
  Everyone in this Chamber wants affordable, quality health care for 
all Americans. This bill fails to do that. So let us begin again. Let 
us work together on legislation to reach the goal the President has set 
and many of us share: insurance for everyone, not just the rich.

[[Page H2436]]

  

  Mrs. BLACK. Mr. Speaker, I yield 1\1/2\ minutes to the distinguished 
gentleman from Florida (Mr. Dunn).
  Mr. DUNN. Mr. Speaker, I rise to repeal ObamaCare by supporting the 
American Health Care Act. We are here to take health care back from the 
bureaucrats and give it to the people.
  The previous administration enacted ObamaCare, and we saw its 
effects: higher premiums, less choice, lost coverage, and broken 
promises. The deductibles are so high it is like not having insurance 
at all.
  The people who sent me to Congress sent me with strict orders: End 
this law. And on the American Health Care Act, I can report, it does.
  With this bill, the Federal Government no longer forces you to buy a 
product you can't use and don't want. The individual mandate is gone, 
so is the job-killing employer mandate. Gone are a host of taxes on 
prescription meds, over-the-counter drugs, insurance premiums, and 
lifesaving medical devices.
  It ends ObamaCare's Medicaid expansion, and it puts Medicaid on a 
budget and focuses State efforts on those people truly in need. This is 
the biggest entitlement reform in a generation.
  Of course the bill is not perfect. There is more to do. But I spent 
30 years as a surgeon. In medicine, as in life, you do not get to 
choose the perfect option. You learn not to make perfect the enemy of 
great.
  With this vote we decide whether ObamaCare is our healthcare future 
or not. We can live with its failures and broken promises or create a 
market-based system that actually lowers the cost of health care and 
serves patients, not bureaucrats.

  So I support the American Health Care Act, Mr. Speaker, and I urge 
that all Members do the same.
  Mr. SCOTT of Virginia. Mr. Speaker, I remind my colleague that his 
vote for this bill will result in 63,900 people from his congressional 
district in Florida losing healthcare coverage and care.
  I yield 1 minute to the gentleman from Connecticut (Mr. Courtney).
  Mr. COURTNEY. Mr. Speaker, in a few minutes, the American people will 
see clearly what each and every Member of this House is made of. Will 
we vote to willfully strip healthcare coverage for 24 million 
Americans, older Americans, working Americans, Americans with chronic 
illness and developmental disabilities and now, incredibly, we even 
know, Americans who wore the uniform of this Nation?
  In a few minutes, we will see who will vote to raid the Medicare 
trust fund in order to cut Medicare taxes for the rich, and we will see 
who will vote to cut Medicaid's coverage for patients struggling with 
the curse of opioid addiction.
  Mr. Speaker, this is not just a vote. This is a gut check of who we 
are as people and whether our purpose, as elected officials, is to 
serve the public interest or, rather, feckless special interests.
  Show the Nation that we care more about people than politics, that we 
care more about the long arc of American history toward justice rather 
than the short news cycle of who is up and who is down in Washington.
  Make no mistake: History is watching this vote. Vote ``no.''
  Mrs. BLACK. Mr. Speaker, I yield 1\1/2\ minutes to the gentleman from 
Louisiana (Mr. Abraham), who is a family practitioner and knows a 
little about medicine.
  Mr. ABRAHAM. Mr. Speaker, as a practicing physician in the Louisiana 
and Mississippi delta, I have some of the best patients, but some of 
the poorest. They can't afford to see me because they can't afford 
ObamaCare, increased costs, skyrocketing premiums, high deductibles. I 
can't cure a disease if I can't see the patient. The cost is just too 
high for ObamaCare.
  We have heard about Medicaid expansion here today. That is a second-
class insurance for first-class people. I can't get my patients to see 
a specialist. They have to go to the hospital. They have to go to the 
emergency room. Prices go through the roof.
  I have heard my colleagues on the other side of the aisle reference 
the Hippocratic Oath. With all due respect, I don't think they would 
know what the Hippocratic Oath says if their life depended on it. Guess 
what? It does. Google it.
  Let me educate you. Let me educate our colleagues. It says I will 
always seek a path to a cure for all diseases. ObamaCare will not let 
me do that.
  We have got to do better. We cannot cram people into a healthcare 
system that has failed just so politicians can thump their chest and 
have some type of mysterious victory that is hollow and very, very 
small.
  We need to pass this American Health Care Act. ObamaCare has failed. 
It is a sham of an insurance. Americans deserve better. We deserve 
better as Americans. My patients deserve better.
  Mr. SCOTT of Virginia. Mr. Speaker, I remind my colleague that his 
vote for this bill will result in 51,700 people in his district losing 
their coverage and care.
  Mr. Speaker, I include in the Record a letter from the American 
Academy of Family Physicians, the American Academy of Pediatrics, the 
American College of Physicians, the American Congress of Obstetricians 
and Gynecologists, and the American Osteopathic Association in 
opposition to the legislation.

 [From the American Academy of Family Physicians, American Academy of 
 Pediatrics, American College of Physicians, The American Congress of 
Obstetricians and Gynecologists, American Osteopathic Association, Mar. 
                                7, 2017]

   America's Front Line Physicians Express Serious Concerns With the 
                        American Health Care Act

       Washington, DC--After the release of the two budget 
     reconciliation bills today, the physician leaders of our 
     organizations, representing over 500,000 physicians and 
     medical students, visited with members of the House of 
     Representatives to urge that they ``First, do no harm'' to 
     our patients by rolling back key coverage, benefits and 
     consumer protections as required under current law, including 
     the Affordable Care Act. We are concerned that by rushing to 
     a mark-up tomorrow in the Energy and Commerce and Ways and 
     Means Committees, there will be insufficient time to obtain 
     non-partisan estimates of this legislation's impact by the 
     Congressional Budget Office, or for medical organizations 
     like ours and other key stakeholders in the health care 
     community to offer substantive input on the bill.
       During our meetings with members of the House of 
     Representatives today, we shared our joint principles for 
     health care reform. They reflect our collective expertise, 
     and represent the health care needs patients present to our 
     members every day. We urge Representatives to utilize these 
     principles to evaluate any legislation to modify current law, 
     and ensure that patients and providers are not adversely 
     affected. While each of our organizations individually are 
     still reviewing the changes proposed by the American Health 
     Care Act, released just hours ago, we share a concern that it 
     will not meet our principles because it will likely result in 
     less access to coverage and higher costs for millions of 
     patients.
       We urge House Speaker Paul Ryan (R-WI) and the chairs of 
     these two committees to reconsider the decision to move 
     forward with mark-up, and instead allow the time needed for a 
     thorough review of the bill to ensure that it meets our 
     overarching principle, ``First, do no harm'' to patients.


            About the American Academy of Family Physicians

       Founded in 1947, the AAFP represents 124,900 physicians and 
     medical students nationwide. It is the only medical society 
     devoted solely to primary care. Family physicians conduct 
     approximately one in five office visits--that's 192 million 
     visits annually or 48 percent more than the next most visited 
     medical specialty. Today, family physicians provide more care 
     for America's underserved and rural populations than any 
     other medical specialty. Family medicine's cornerstone is an 
     ongoing, personal patient-physician relationship focused on 
     integrated care. To learn more about the specialty of family 
     medicine, the AAFP's positions (5 page PDF) on issues and 
     clinical care, and for downloadable multi-media highlighting 
     family medicine, visit www.aafp.org/media. For information 
     about health care, health conditions and wellness, please 
     visit the AAFP's award-winning consumer website, 
     www.family
     doctor.org).


                About the American Academy of Pediatrics

       The American Academy of Pediatrics is an organization of 
     66,000 primary care pediatricians, pediatric medical 
     subspecialists and pediatric surgical specialists dedicated 
     to the health, safety and well-being of infants, children, 
     adolescents and young adults. For more information, visit 
     www.aap.org and follow us on Twitter @AmerAcadPeds.


                About the American College of Physicians

       The American College of Physicians is the largest medical 
     specialty organization in the United States. ACP members 
     include 148,000 internal medicine physicians (internists), 
     related subspecialists, and medical students. Internal 
     medicine physicians are specialists who apply scientific 
     knowledge and clinical expertise to the diagnosis, treatment, 
     and compassionate care of adults across the spectrum from 
     health to complex illness. Follow ACP on Twitter and 
     Facebook.

[[Page H2437]]

  



     About the American Congress of Obstetricians and Gynecologists

       The American College of Obstetricians and Gynecologists 
     (The College), a 501(c)(3) organization, is the nation's 
     leading group of physicians providing health care for women. 
     As a private, voluntary, nonprofit membership organization of 
     more than 57,000 members. The College strongly advocates for 
     quality health care for women, maintains the highest 
     standards of clinical practice and continuing education of 
     its members, promotes patient education, and increases 
     awareness among its members and the public of the changing 
     issues facing women's health care. The American Congress of 
     Obstetricians and Gynecologists (ACOG), a 501(c)(6) 
     organization, is its companion.


               About the American Osteopathic Association

       The American Osteopathic Association (AOA) represents more 
     than 129,000 osteopathic physicians (DOs) and osteopathic 
     medical students; promotes public health; encourages 
     scientific research; serves as the primary certifying body 
     for DOs; and is the accrediting agency for osteopathic 
     medical schools. Visit DoctorsThatDo.org to learn more about 
     osteopathic medicine.

  Mr. SCOTT of Virginia. Mr. Speaker, I yield 1 minute to the 
gentlewoman from Ohio (Ms. Fudge).
  Ms. FUDGE. Mr. Speaker, what is a life worth? What does it cost to 
save the life of a sick child or a senior citizen?
  For all of the rhetoric about freedom and choices, this bill sends a 
clear message to every American as to where Republican priorities lie. 
Tax breaks to the wealthy have been deemed more valuable than 
lifesaving care.
  They are telling hardworking families that insurance that only 
benefits the wealthy, the healthy, and the young is more important than 
access to nursing homes, to pediatric care, mental health services, 
substance abuse treatment, and the overall peace of mind that, if you 
get sick, you can afford care.
  Speaker Ryan calls this ``an act of mercy.'' This is by no means 
merciful, Mr. Speaker. Mercy is caring for the sick, the poor, for our 
elders. Mercy is extending a hand to those in need. This is heartless.
  Human decency demands a ``no'' vote on TrumpCare. Vote ``no.''
  Mrs. BLACK. Mr. Speaker, I yield 2 minutes to the gentleman from 
Texas (Mr. Conaway), the chairman of the Agriculture Committee.
  Mr. CONAWAY. Mr. Speaker, we are faced with an unenviable choice of 
the fact that there is infinite demand for health care. There is no top 
on the amount of healthcare cost necessary to provide all the health 
care that we want for everybody in this country, and we have limited 
resources within which to do that.
  The real question is: Does ObamaCare take up that task by asking 
government to make those hard choices, or do we as individuals and 
families and caregivers make those harder choices for ourselves?
  I believe that the bill that we will get to vote on today moves us 
toward that direction. This isn't about health care, per se; this is 
about how do you pay for it.
  Insurance is not a magic bullet anywhere across the spectrum. 
Insurance is simply a scheme in which we risk-manage together. We put a 
certain amount of money into a bucket, assuming not all of us will 
suffer the risks that we want to cover. If we do, we have got to put 
more money in; if we don't, then the system works.
  This is about having to confront that choice that there is way too 
much cost for the amount of resources that are available in any of 
these circumstances, and it is hard.
  Many of my constituents ask: Why did Republicans spend 6 years 
railing against ObamaCare and not have the fix available on 
Inauguration Day? Well, this is Exhibit A. This is hard stuff. Even 
among Republicans, we have got more than 218 votes among us, and we 
can't agree among ourselves necessarily what ought to go forward.
  But I do know this, that we are down to the final choice: Do we keep 
ObamaCare and the failure that is confronting us and will continue to 
be there, or do we take a chance on moving toward something different, 
moving toward freedom, moving toward choice, giving States back the 
opportunity to decide for their indigent population how they should 
take care of them?
  I don't think anybody in Washington, D.C., can come up with a plan 
that fixes that for all 50 States. I trust my colleagues in Austin to 
make that happen far better than anybody I would trust in D.C., and 
this bill moves that direction, and that is the right direction for us 
to go.
  This is a hard choice, but for me it is relatively straightforward. 
You keep ObamaCare with a ``no'' vote. You move toward a brighter 
future for health care in this country and the way we pay for it, who 
pays for it, and how we get that done by a ``yes'' vote. I encourage my 
colleagues to vote ``yes'' on this bill.
  Mr. SCOTT of Virginia. Mr. Speaker, I remind my colleague that his 
vote for this bill will result in making things worse by 58,600 people 
in his district losing their healthcare coverage and care.
  Mr. Speaker, I yield 1 minute to the gentlewoman from Florida (Ms. 
Wilson).
  Ms. WILSON of Florida. Mr. Speaker, I would like to begin by asking 
my Republican colleagues one simple question: Don't you have 
constituents who get sick and need insurance?
  Everyone gets sick, rich and poor, Black and White, men, women, and 
children.
  Having insurance gives us peace of mind. It helps ensure that a 
medical crisis is not exacerbated by a financial crisis. It often makes 
a difference between life and death. If the Affordable Care Act is 
repealed, your constituents and millions of people will be kicked off 
the insurance roll, and that is a shame. They will suffer, and their 
families will suffer.
  I have health insurance, and so does every Member of Congress. We 
even have a clinic and doctors at our disposal right here in this 
Capitol.
  Doesn't every American deserve the same treatment as Members of 
Congress?
  Instead of moving backwards, Republicans should partner with 
Democrats to amend and strengthen the existing law. By working 
together, we can create a plan that works for all Americans, not just 
the Members of Congress. Vote ``no.'' Vote ``no.''
  Ms. KAPTUR. Mr. Speaker, the Affordable Care Act needs to be 
repaired, not repealed. In 2010, Democrats passed health care reform in 
an effort to move toward health insurance for all Americans. Though we 
have made progress and more work to do, we cannot move America 
backward. Tens of thousands of people in northern Ohio and millions 
across America will lose insurance if TrumpCare becomes law.
  This bill is cruel. It will take away care from some of our most 
vulnerable citizens like those who suffer from opioid addiction, mental 
illness or have disabilities. This bill will undermine Medicare and cut 
$28 billion from Ohio's Medicaid program, the majority of which is 
spent on nursing home care. If Republicans succeed in repealing the 
Medicaid expansion, one in four Ohio hospitals would close according to 
the Ohio Hospital Association.
  Our goal should be to make our health care system better, not worse. 
This merciless bill is not a health care bill. This bill is an $800 
billion tax cut for corporations and the very rich. How that giveaway 
provides better health care to working and middle-class families is 
beyond me.
  For Lent I gave up chocolate, I recommend the Republicans try giving 
up tax cuts to the rich!
  Let me share a story about a young man in Ohio who was diagnosed with 
an extremely rare form of cancer one month before his 26th birthday.
  Once he turned 26 he lost coverage under his parent's health care 
policy.
  But after visiting an Ohio Jobs and Family Services office, he 
learned about his eligibility for the Ohio Medicaid expansion, which 
allowed him to receive the cancer treatment he needed to survive.
  Frankly, without the Affordable Care Act's multi-layered protections, 
he would be dead.
  The Affordable Care Act and its Medicaid expansion has allowed him to 
return to finish law school.
  This bill shifts the burden of health costs to the working and middle 
class, all so the rich can have a trillion dollar tax cut. A tax cut 
for the super rich doesn't help working people and seniors pay for 
health care. Astoundingly, the falsely labeled, so called ``health'' 
bill actually rewards billionaires and corporations with hundreds of 
billions in tax giveaways.
  This bill does nothing to control costs for health insurance. 
Millions will lose coverage. It will actually result in higher costs 
too all while undermining Medicare and slashing Medicaid.
  Congress ought to repair not repeal the ACA. We cannot move backward. 
This GOP bill is cruel and some of our most challenged

[[Page H2438]]

citizens like the mentally ill or disabled will lose care. Premiums for 
those over 50 could increase by 5 fold. As the old saying goes; ``this 
dog won't hunt.''
  Ohio embraced the ACA and 866,000 people were finally able to receive 
health care coverage. What will this poorly conceived Republican tax 
giveaway bill do to Ohio:
  1. About 47,000 people will lose health insurance because they are 
insured through the ACA in Ohio's 9th district.
  2. The district's uninsured rate has gone from 13.3% to 7.0% since 
the ACA was implemented. This 6.3 percentage point drop in the 
uninsured rate could be reversed if the ACA is entirely or partially 
repealed.
  3. 318,900 individuals in the district who now have health insurance 
that covers preventive services like cancer screenings and flu shots 
without any co-pays, coinsurance, or deductibles stand to lose this 
access if the Republican Congress eliminates ACA provisions requiring 
health insurers to cover important preventive services without cost-
sharing.
  4. 370,700 individuals in the district with employer-sponsored health 
insurance are at risk of losing important consumer protections like the 
prohibition on annual and lifetime limits, protection against unfair 
policy rescissions, and coverage of preexisting health conditions, if 
the ACA is entirely or partially repealed.
  This Republican bill, hastily prepared, should be defeated. It is 
cruel, will leave millions of our fellow citizens bankrupt and 
destitute, and if implemented, will be responsible for more death and 
illness coast to coast. Vote no on TrumpCare.
  Mr. LYNCH. Mr. Speaker, I rise in strong opposition to H.R. 1628, the 
American Health Care Act of 2017.
  Mr. Speaker, I have received countless visits, calls, letters and 
emails from constituents about this bill. I have heard from hospitals, 
doctors, patients, nurses, parents of children with serious illnesses, 
researchers and the list goes on. They have one thing in common: they 
are afraid of what TrumpCare could do to their patients and to their 
families.
  H.R. 1628 will not bring down health care costs or improve access. 
Indeed, by slashing Medicaid by $880 billion, it will force States to 
ration care for our most vulnerable populations. In Massachusetts, this 
cut will put the health of 1.9 million people at risk, including 
650,000 children, 170,000 seniors and 280,000 people with disabilities. 
My state is also being hit hard by the opiate addiction crisis and 
cutting Medicaid will cripple our ability to address that problem. It 
is also a disgrace that the funding being cut out of Medicaid is being 
handed over to insurance companies and the wealthiest Americans in a $1 
trillion tax break for the rich.
  TrumpCare slashes $175 billion from the Medicare Trust Fund, cutting 
its solvency by three years and hurts seniors by letting insurance 
companies charge older Americans five times more than they do young 
ones. The yearlong bar on reimbursements to Planned Parenthood for non-
abortion services means that women will have to go without health 
screenings, pre-natal care and well-woman visits. And according to the 
C.B.O., 24 million Americans will no longer have health insurance 
coverage.
  All this begs the question, how does this bill provide better care 
for Americans?
  But you do not have to take my word for it when I say that this bill 
will hurt Americans. Groups like the American Medical Association, the 
American College of Physicians, the American Academy of Pediatrics and 
the American Nurses Association, just to name a few, are urging 
Congress to stop TrumpCare. These are the men and women who are out 
there on the front lines everyday treating and healing our fellow 
Americans.
  To make things worse, TrumpCare is being rushed to the floor with 
minimal deliberation. It was introduced less than three weeks ago and 
we have not held a single hearing or heard from a single expert witness 
on it. Now we are being asked to vote on it despite receiving the 
newest version of the manager's amendment late last night. This is not 
the regular order and transparency that the Republicans promised.
  Mr. Speaker, this bill pushes the cost of health care onto those who 
can least afford it while providing massive tax cuts for the wealthy. I 
urge my fellow members to defeat this misguided bill and let us begin 
the serious work of making real improvements in the Affordable Care Act 
for all Americans.
  Mrs. BEATTY. Mr. Speaker, I rise today to express my opposition to 
TrumpCare and my strong support for the Affordable Care Act.
  Since the ACA was enacted seven years ago, more than 20 million 
Americans have gained access to affordable and high quality health 
insurance, including nearly one million Ohioans.
  We thought 129 million Americans with pre-existing conditions would 
be able to keep their health care coverage. We thought 105 million 
Americans would no longer have to worry about annual or lifetime 
limits. Yet, we are here today winding back the clock on all the 
progress we have made based on a bill that wasn't released to the 
public until last night.
  What's the rush to pass a bill that affects so many people without 
letting the public view it? What's the rush to pass a bill that affects 
so many people without a new CBO score?
  Mr. Speaker, we know that TrumpCare will cause Americans to pay more 
for less coverage. We know that TrumpCare will provide a massive tax 
cut to the super rich 400 families and leave the other 99.9 percent of 
people behind. We know that TrumpCare will cause 24 million Americans 
to lose their health insurance, including tens of thousands of my 
constituents in the Third Congressional District of Ohio. We know that 
TrumpCare will slash Medicaid funding by $880 billion. We also know 
that TrumpCare will put 13 million children, people with disabilities 
and adults just one emergency visit away from financial catastrophe.
  Mr. Speaker, these cuts hurt people all across the country. TrumpCare 
will not make healthcare more affordable.
  Democrats believe healthcare is a right, not a privilege. I join my 
colleagues in fighting for affordable healthcare for all Americans. I 
will vote no, and urge all my colleagues to vote no as well.
  Mr. SMITH of New Jersey. Mr. Speaker, while the Affordable Care Act 
has been in effect since 2010, it has only provided actual access to 
health insurance benefits through the exchange and Medicaid expansion 
for a little over 3 years--beginning in 2014.
  In that short period of time, however, serious problems and flaws 
have been exposed, yet in recent months the law's systemic problems 
have been trivialized or ignored by many.
  Today, buying an insurance policy on the exchanges with high 
premiums, high copays, and most importantly, exceedingly high 
deductibles make the actual utilization of health benefits far costlier 
than originally advertised.
  Americans were told repeatedly that the ACA would save up to $2,500 
in premium payments per family per year. President Obama said: ``I will 
sign a universal health care bill into law by the end of my first term 
as president that will cover every American and cut the cost of a 
typical family's premium by up to $2,500 a year.''
  That didn't happen--not even close.
  Nationwide, since 2016, gross premiums before subsidies in the 
Bronze-priced tier rose a whopping 27 percent, silver 24 percent and 
gold 32 percent.
  That should come as no surprise. As early as August 2012, Politifact 
found President Obama's promise to be untrue and labeled the statement 
a ``promise broken'' in a Politifact report entitled: NO cut in 
premiums for typical family.
  Health insurance consumers were promised they could keep their 
insurance plan if they liked it and keep their trusted doctors as well. 
That didn't happen either.
  As a matter of fact, several million were kicked off insurance plans 
they were very satisfied with--like my wife and I--only to be forced 
into an Obamacare plan that we didn't want and was more expensive.
  Also, in New Jersey--like much of the nation--insurance companies are 
pulling out of the exchanges. Insurers continue to exit the individual 
market and the exchange has experienced a net loss of 88 insurers. 
Today, five states only have one insurer option. At home, last year 
five insurance carriers offered plans on the New Jersey exchange, today 
only two remain. The exodus of insurance companies from the individual 
market is an unsustainable and ominous trend.
  Mr. Speaker, almost twice as many Americans have paid the financial 
penalty--pursuant to what is euphemistically called the ``individual 
mandate''--for not buying a health insurance plan--or have received an 
exemption from the individual mandate as those who have actually 
purchased a plan through the exchange. By the numbers that means 19.2 
million taxpayers either paid the individual mandate penalty or claimed 
an exemption, compared to 10.3 million individuals who paid for plans 
on the Obamacare exchanges.
  Obamacare also increased taxes by about one trillion dollars.
  For example, beginning in 2020, a new 40% excise tax on employer 
provided comprehensive health insurance plans is scheduled to take 
effect. Any plan provided by an employer exceeding $10,200 for 
individuals and $27,500 for families will be taxed at 40 percent for 
each dollar above those numbers. According to the Kaiser Family 
Foundation this so-called Cadillac tax will hit 26 percent of employers 
by 2020.
  According to the IRS, approximately 10 million families took 
advantage of the chronic care tax deduction which is now been redefined 
out of reach for many. New taxes combined with skyrocketing premiums, 
copays and deductibles underscores the need for serious review, 
reevaluation and reform.
  That said Mr. Speaker, I remain deeply concerned--and will vote no 
today--largely because the pending bill cuts Medicaid funding

[[Page H2439]]

by an estimated $839 billion over ten years according to the 
Congressional Budget Office (CBO), rolls back Medicaid expansion, 
cancels essential health benefits such as maternity and newborn care, 
hospitalization, pediatric services, and mental health and substance 
use treatment, and includes ``per capita caps''--all of which will 
likely hurt disabled persons, the elderly and the working poor.
  For years, I have supported Medicaid expansion as a meaningful way of 
providing access to health care for struggling individuals and families 
living above the poverty line but still poor despite being employed--80 
percent of all Medicaid enrollees in New Jersey are families with at 
least one working adult in 2017.
  Although more than 800,000 children are served by Medicaid in my 
state, the bulk of Medicaid funds are spent assisting the disabled and 
the elderly. In New Jersey approximately 74 percent of all Medicaid 
spending goes directly to assist persons with disabilities and senior 
citizens. Two out of every five people in nursing homes are on 
Medicaid.
  According to the New Jersey Department of Human Services, in New 
Jersey total enrollment in Medicaid in February 2017 was 1.77 million 
people. Of that a significant number are newly enrolled under Medicaid 
expansion--663,523 ``newly eligible.''
  These people are in need and deserve our support. Current law 
provides states that opted to embrace Medicaid Expansion--like New 
Jersey--95 percent of the costs for the ``newly enrolled.'' The federal 
share drops to 90 percent by 2020.
  The proposed American Health Care Act continues Medicaid expansion 
however only until 2020. Those enrolled before December 31, 2019 would 
be grandfathered in at the 90 percent match rate but the federal-state 
match formula would then be reduced to a range between 75 percent-25 
percent to 50 percent-50 percent or any new enrollee.
  What does that mean?
  The United State Conference of Catholic Bishops wrote each of us on 
March 17th: ``. . . it is our assessment that some provisions are 
commendable (and they reference the pro-life safeguards and other 
noteworthy provisions in the bill) . . . while others present grave 
challenges that must be addressed before passage . . . millions of 
people who would be eligible for Medicaid under current law will be 
negatively impacted due to reduced funding from the per capita cap 
system proposed in the legislation, according to the CBO. Those 
struggling families who currently receive Medicaid coverage from the 
recent expansion will see dramatic changes through the AHCA as well, 
without clear indication of affordable, adequate coverage to replace 
their current options. Many states begin their legislative sessions 
every cycle by attempting to overcome major deficits. State and local 
resources are unlikely to be sufficient to cover the gaps that will be 
created in the health care system as financial responsibility is 
further shifted to the states. Congress must rework the Medicaid-
related provisions of the AHCA to fix these problems and ensure access 
for all, and especially for those most in need.''
  A letter led by the Consortium For Citizens with Disabilities, and 
signed by over 60 organizations states:
  ``Dramatic reductions in federal support for Medicaid will force 
states to cut services and/or eligibility that puts the health and 
wellbeing of people with disabilities at significant risk. In fact, 
people with disabilities are particularly at risk because so many 
waiver and home- and community-based services are optional Medicaid 
services and will likely be the first services cut when states are 
addressing budgetary shortfalls. The health, functioning, independence, 
and wellbeing of 10 million enrollees living with disabilities and, 
often, their families, depends on funding the services that Medicaid 
provides. Likewise, Medicaid Expansion provides coverage for millions 
of people with disabilities and their caregivers who previously fell 
into healthcare coverage gaps. For many people with disabilities, being 
able to access timely, needed care is a life or death matter. The 
drastic cuts to Medicaid that will result from per capita caps and the 
ultimate elimination of Medicaid Expansion will endanger millions.''
  Autism Speaks, a leading autism awareness, science, and advocacy 
group, further articulated another concern, that ``the choice of 2016 
as a baseline year for per capita caps may prevent states from 
addressing the needs of children with autism. In July 2014 the Center 
for Medicaid and CHIP Services issued an informational bulletin 
clarifying Medicaid coverage of services to children with autism, 
including benefit requirements for the Early and Periodic Screening, 
Diagnostic, and Treatment (EPSDT) program. Although EPSDT is a 
mandatory Medicaid program, few states in 2016 funded autism services 
at the required standard of care. Locking in 2016 as a baseline year 
can only perpetuate this historic underfunding of EPSDT benefits.''
  Ms. ROYBAL-ALLARD. Mr. Speaker, for my constituents and all 
Americans, Trumpcare would result in higher costs, less coverage, a 
crushing age tax for persons 50 to 64, a shorter Medicare life span, 
and the ransacking of the Medicaid funds that enable seniors to get the 
long term care they need. And last night, Republicans added a provision 
that would prohibit our veterans who are eligible to receive VA care 
from receiving any tax credits to help pay for their care outside the 
VA, even if they are not enrolled in the VA.
  In my congressional district, the uninsured rate dropped from 31.7 to 
17.5 percent due to Obamacare.
  Among my constituents who benefited are a young mother from Bell 
Gardens, California, and her 15-month-old daughter, Olivia, who was 
born with Down Syndrome.
  Because of Obamacare's Medicaid expansion in California, Olivia was 
able to have her congenital heart defect repaired shortly after birth. 
She is now being followed by a cardiologist to ensure her ongoing care 
for a healthy heart.
  Obamacare's Medicaid expansion also makes it possible for baby Olivia 
to receive early intervention and physical therapy services to enhance 
and accelerate her development.
  Olivia's mom is terrified that if Trumpcare passes, her daughter may 
not be able to receive these services, which help her remain healthy 
and make it possible for her to reach critical developmental 
milestones.
  Republicans like to call Obamacare a failed disaster. That is simply 
one more example of their ``alternative facts.''
  The Republican Trumpcare bill before us is the disaster waiting to 
unfold for countless families like Olivia's, and millions of Americans 
across our country.
  I urge my colleagues to vote no on behalf of the American people.
  Ms. EDDIE BERNICE JOHNSON of Texas. Mr. Speaker, I rise in strong 
opposition to H.R. 1628, the American Health Care Act, which not only 
seeks to repeal the Patient Protection and Affordable Care Act, but 
reform entitlements, redistribute wealth, and strip coverage from 
millions of people.
  The American Health Care Act would reduce coverage for Americans 
while increasing out-of-pocket costs for the sickest and the elderly. 
Health plans would fail to meet the needs of Americans with chronic or 
complex conditions. The bill also eliminates protections against annual 
and lifetime caps. With a last-minute manager's amendment to repeal the 
Essential Health Benefits, the ten coverage rules set up by the 
Affordable Care Act, this ruthless bill has gotten even worse.
  The Affordable Care Act required insurers to cover ten ``Essential 
Health Benefits'' from maternity care, mental health, and prescription 
drugs, to hospitalization and outpatient care. If this is repealed, 
comprehensive health insurance will become virtually unavailable in the 
individual market. This means that individuals with pre-existing 
conditions would not be protected. Younger and healthier people 
benefit, older and sicker people suffer.
  While the new additions to this measure are startling, the original 
bill is just as shocking. Slashing and capping the Medicaid program 
will ration care and give tax breaks to the wealthy. This bill cuts 
$880 million from Medicaid and then caps the program so that it cannot 
expand and contract as needed. By the end of 2019, the Medicaid 
expansion program will freeze and this bill will shift costs to states 
for the elderly, children, individuals with disabilities, and low-
income adults.
  This bill will kick 24 million people off their health insurance by 
2026, and 7 million people will lose their employer-based coverage. 
While the Affordable Care Act subsidies were based on income and when 
premiums rose, the federal subsidy also rose to pay for premium costs, 
the American Health Care Act replaces those subsidies with a fixed 
credit amount. The age-based tax credits are a refundable tax credits 
that is larger for older individuals, however, it allows insurers to 
charge older enrollees five times more than a younger enrollee.
  Mr. Speaker, the public has spoken about this so-called 
``replacement'' bill. People will live or die as a result of this 
legislation. This bill will force Americans to pay more for their 
premiums, more for their care, more on out-of-pocket expenses and 
deductibles; all the while giving tax breaks directly to the wealthy. 
The Republican leadership has rushed this bill to the floor without any 
consideration and I urge you all to consider its harmful effects. Your 
constituents are asking you to work with us to repair the Affordable 
Care Act. Work with us.
  Mr. AL GREEN of Texas. Mr. Speaker, although Trumpcare is a terrible 
Healthcare plan, it is a terrific Wealthcare plan.
  Trumpcare is terrific Wealthcare because in the final analysis, it 
allows the 400 richest families to get $7 million a year ad infinitum, 
$7 million a year forever.
  In the final analysis, 79% of the cuts become Wealthcare dollars for 
the very rich, not healthcare dollars for the very poor.

[[Page H2440]]

  In the final analysis, it sacrifices $1 trillion from Medicare and 
Medicaid to enrich the lives of millionaires and billionaires.
  In the final analysis, it provides more money for Wealthcare and less 
money for Healthcare.
  Mr. Speaker, Trumpcare is more Wealthcare and less Healthcare.
  Mr. CONYERS. Mr. Speaker, I've been here a while and it's hard for me 
to recall a time when we've voted on something so obviously and 
willfully harmful to children, seniors and working Americans.
  This bill strips healthcare from 24 million people.
  It requires some seniors to pay 100 percent or more of their income 
in premiums.
  This legislation dramatically cuts Medicaid, directly contradicting 
President Trump's claim not to.
  In Michigan, HALF of all children rely on Medicaid.
  In my district alone, 56,000 people will lose coverage, including 
16,000 children.
  Let's be clear: if we pass this bill, children, seniors, and working 
people will suffer and some will die, so that the wealthy can get a tax 
cut.
  Healthcare is a right, not a privilege. That's why I support a 
single-payer, Medicare-for-All plan, and why I will be voting ``no'' on 
this mean spirited legislation.
  Mr. Speaker, as Ranking Member on the House Judiciary Committee, I 
include in the Record a legal analysis prepared by committee staff that 
concludes that the provision of H.R. 1628 that requires New York State 
to change how its counties fund the State's portion of Medicaid 
expenses is not related to a legitimate Federal interest, that no 
rational Federal purpose has been proffered for the provision, and that 
it would severely intrude on traditional state prerogatives. As such, 
this provision would violate Constitutional limits on the Federal 
Spending Power, the Due Process and Equal Protection Clauses and the 
Tenth Amendment (reserving all undelegated powers to the States) and 
would likely be held unconstitutional if challenged in court.

                               Memorandum

     To: Interested Members.
     From: House Judiciary Committee Democratic Staff.
     Re: Constitutionality of Faso-Collins Amendment.
     Date: March 24, 2017.
       The Faso-Collins amendment, incorporated into the Manager's 
     amendment, would violate Constitutional limits on the Federal 
     Spending Power, the Due Process and Equal Protection Clauses 
     and the Tenth Amendment (reserving all undelegated powers to 
     the States). Requiring New York State to change how its 
     counties Fund its portion of Medicaid expenses is not related 
     to a legitimate Federal interest, no rational Federal purpose 
     has been proffered for the provision, and it would severely 
     intrude on traditional state prerogatives.
       If the Faso-Collins amendment were ever enacted, it quickly 
     would be invalidated by the Federal courts. The irony of this 
     ``buyout'' is that the ``payment'' supposedly being delivered 
     in exchange for votes--the unconstitutional provision--is the 
     legislative equivalent of a check on a closed bank account, 
     which will never deliver the promised benefits.
       For the last 51 years, New York State has chosen to fund a 
     portion of its share of the Medicaid Program by using funds 
     from county property taxes. Fifteen other States structure 
     Medicaid funding through a similar legally authorized system.
       The Faso-Collins amendment specifies that any State that 
     had an allotment of Disproportionate Share Hospital (DSH) 
     funds that was more than 6 times the national average, and 
     that requires subdivisions with populations of less than 
     5,000,000 to contribute toward Medicaid costs, shall have its 
     reimbursement reduced by the amount of contributions by such 
     subdivisions. (This effectively limits the application to New 
     York State, and carves out New York City.) Under the 
     amendment, New York State is at risk of losing $2.3 billion 
     of its $32 billion in Federal Medicaid funds.
       This provision is unconstitutional, and could be struck 
     down for several reasons:
       Violation of Limits on Spending Power--Article I of the 
     Constitution grants Congress spending power to ``provide for 
     the . . . general Welfare.'' In South Dakota v. Dole, 483 
     U.S. 203 (1987), the Supreme Court held that any spending 
     condition imposed on the States must be related to the 
     Federal interest in that particular project or program and 
     that Congress cannot coerce the States into compliance with 
     the Federal government's objectives. In NFIB v. Sebelius, 132 
     S. Ct. 2566 (2012), the Supreme Court found provisions of the 
     Affordable Care Act which required all States to comply with 
     the law's Medicaid expansion violated this spending 
     authority, noting the ``Constitution has never been 
     understood to confer upon Congress the ability to require the 
     States to govern according to Congress' instructions.'' The 
     Faso-Collins language does not appear to be related to any 
     Federal interest in the use or allocation of Federal Medicaid 
     funds: it does not further Medicaid's purposes and has 
     nothing to do with ensuring the proper disbursement of 
     Federal funds. Indeed, because the provision applies to 
     counties in a single State--and leaves the very same system 
     undisturbed in 15 other States--it could not possibly be 
     justified by any legitimate Federal interest.
       An additional line of Supreme Court cases, including New 
     York v. United States, 505 U.S. 144, 167, 172 (1992), has 
     held that conditions on Federal grants must be ``reasonably 
     related to the purpose of the [Federal] expenditure'' because 
     otherwise ``the spending power could render academic the 
     Constitution's other grants and limits of Federal 
     authority.'' Likewise, in Massachusetts v. United States, 435 
     U.S. 444, 461 (1978), the Supreme Court noted that it has 
     ``repeatedly held that the Federal Government may impose 
     appropriate conditions on the use of Federal property or 
     privileges and may require that State instrumentalities 
     comply with conditions that are reasonably related to the 
     Federal interest in particular national projects or 
     programs.'' Under these precedents, the Faso-Collins language 
     would be held to be an arbitrary exercise of Federal power 
     which intrudes on only one particular State's sovereign tax 
     powers, and is unrelated to any Federal interest or purpose 
     in the Medicaid Program.
       As Yale Law School Professor Abbe Gluck wrote in a post on 
     the Balkinzation blog today, the Faso-Collins ``amendment is 
     likely unconstitutional. The protection from federal 
     interference of the internal functions of a state government 
     is one of the bedrocks of state sovereignty protected by the 
     limitations on Congress's powers in Article I of the 
     Constitution and the reservation of power to the states in 
     the Tenth Amendment.'' She further reasoned that ``Even if 
     one could argue that this is an exercise of the federal 
     spending power under Article I, for Congress to legally use 
     that power, the conditions on a state's use of federal 
     funding have to be tied to a reasonable federal propose . . . 
     It is hard to see a reasonable federal purpose here other 
     than garnering more GOP votes for the struggling repeal 
     bill.'' (available at https://ballkin.blogspot.com/2017/03/
is-gop-aca-repealer-unconstitutional-on.html?m=1)
       Violation of Due Process and Equal Protection--Under the 
     Fifth Amendment, the Federal government is not permitted to 
     deprive its citizens of equal protection or due process of 
     law. Those clauses have been interpreted on numerous 
     occasions to prevent the government from discriminating 
     between the treatment of the sovereign States absent a 
     rational basis. For example, in Helvering v. David, 301 U.S. 
     619, 640 (1937), the Supreme Court warned that Congress does 
     not possess the right to demonstrate a ``display of arbitrary 
     power'' in its treatment of the various States. In this 
     regard, in 2009, when an earlier Senate version of the 
     Affordable Care Act sought to provide special treatment for 
     Nebraska with respect to Medicaid reimbursements, 13 
     Republican State attorneys general wrote to Congress 
     (available at http://www.law.columbia.edu/sites/default/
files/microsites/career-servicesifiles/Letter%20to% 
     20the%20 Honorable%20Nancy %20Pelosi%20 and%20the 
     %20Honorable%20Harry %20Reid.pdf) asserting the provision was 
     unconstitutional (the provision was ultimately dropped). In 
     the case of the Faso-Collins language, there is no legitimate 
     policy justification for developing a special rule limiting 
     Medicaid funds for New York as compared to all other States, 
     including 15 States which have sharing agreements with their 
     counties. Nor has a justification been offered for why New 
     York City should be excluded from the application of the 
     special rule. As such, it is clear that the provision is 
     discriminatory, ``arbitrary'' and has no rational basis.
       Abrogation of Tenth Amendment Principles--The Tenth 
     Amendment provides in relevant part that powers not delegated 
     to the Federal government or prohibited to the States are 
     reserved for the States. This has been read to prevent the 
     federal government from ``commandeering'' the states to serve 
     its own purposes. In Printz v. United States, 521 U.S. 898 
     (1997), the Supreme Court held that Congress cannot 
     commandeer State officers to implement Federal policy--in 
     that case requiring criminal background checks for handgun 
     purchases pursuant to the Brady Handgun Violence Prevention 
     Act. The Faso-Collins language commandeers New York State 
     government to facilitate the partisan political ends of a 
     faction in the U.S. Congress, which would seem well outside 
     the proscriptions of Printz. In fact, by essentially ordering 
     New York to reorganize its internal affairs, the Faso-Collins 
     amendment may run even further afoul of Tenth Amendment 
     principles than was the case in Printz given the lack of a 
     Federal purpose and the interference with the core sovereign 
     function of how a State chooses to use its taxing power.
       It is of particular constitutional concern that the Faso-
     Collins provision directly interferes with New York's 
     internal decisions about how to structure its own tax and 
     spending policies, and how to allocate those responsibilities 
     between the State and its subdivisions--which is a core 
     function of a sovereign entity protected by the Tenth 
     Amendment (and potentially Article IV Sec. 4 of the 
     Constitution, which provides that the ``United States shall 
     guarantee to every State in this Union a Republican Form of 
     Government.''). This is constitutionally significant because 
     in Reynolds v. Sims, 377 U.S. 533, 575 (1964), the Supreme 
     Court held that political subdivisions such as counties and 
     cities ``have been traditionally regarded as subordinate 
     governmental instrumentalities created by the State to assist 
     in the carrying

[[Page H2441]]

     out of State governmental functions.'' In Hunter v. City of 
     Pittsburgh, 207 U.S. 161, 178 (1907), the Court noted that 
     these subdivisions are ``created as convenient agencies for 
     exercising such of the governmental powers of the state, as 
     may be entrusted to them'' and that the ``number, nature, and 
     duration of powers conferred upon these [entities] and the 
     territory over which they shall be exercised rests in the 
     absolute discretion of the state.'' The Faso-Collins 
     amendment purports to invoke Federal power to displace New 
     York's sovereign exercise of this ``absolute discretion'' 
     and, for that reason, violates the Constitution. As Chief 
     Justice John Marshall long ago explained in Gibbons v. Ogden, 
     22 U.S. 1, 198-200 (1824), the States' ``power of taxation is 
     indispensable to their existence. . . . In imposing taxes for 
     State purposes, [States] are not doing what Congress is 
     empowered to do. Congress is not empowered to tax for those 
     purposes which are within the exclusive province of the 
     States.''
                                  ____

                                   Office of the Attorney General,


                                      State of South Carolina,

                                                December 30, 2009.
     Hon. Nancy Pelosi,
     Speaker, House of Representatives,
     Washington, DC.
     Hon. Harry Reid,
     Majority Leader, U.S. Senate,
     Washington, DC.
       The undersigned state attorneys general, in response to 
     numerous inquiries, write to express our grave concern with 
     the Senate version of the Patient Protection and Affordable 
     Care Act (``H.R. 3590''). The current iteration of the bill 
     contains a provision that affords special treatment to the 
     state of Nebraska under the federal Medicaid program. We 
     believe this provision is constitutionally flawed. As chief 
     legal officers of our states we are contemplating a legal 
     challenge to this provision and we ask you to take action to 
     render this challenge unnecessary by striking that provision.
       It has been reported that Nebraska Senator Ben Nelson's 
     vote, for H.R. 3590, was secured only after striking a deal 
     that the federal government would bear the cost of newly 
     eligible Nebraska Medicaid enrollees. In marked contrast all 
     other states would not be similarly treated, and instead 
     would be required to allocate substantial sums, potentially 
     totaling billions of dollars, to accommodate H.R. 3590's new 
     Medicaid mandates. In addition to violating the most basic 
     and universally held notions of what is fair and just, we 
     also believe this provision of H.R. 3590 is inconsistent with 
     protections afforded by the United States Constitution 
     against arbitrary legislation.
       In Helvering v. Davis, 301 U.S 619, 640 (1937), the United 
     States Supreme Court warned that Congress does not possess 
     the right under the Spending Power to demonstrate a ``display 
     of arbitrary power.'' Congressional spending cannot be 
     arbitrary and capricious. The spending power of Congress 
     includes authority to accomplish policy objectives by 
     conditioning receipt of federal funds on compliance with 
     statutory directives, as in the Medicaid program. However, 
     the power is not unlimited and ``must be in pursuit of the 
     `general welfare.' '' South Dakota v. Dole, 483 U.S. 203, 207 
     (1987). In Dole the Supreme Court stated, ``that conditions 
     on federal grants might be illegitimate if they are unrelated 
     to the federal interest in particular national projects or 
     programs.'' Id. at 207. It seems axiomatic that the federal 
     interest in H.R. 3590 is not simply requiring universal 
     health care, but also ensuring that the states share with the 
     federal government the cost of providing such care to their 
     citizens. This federal interest is evident from the fact this 
     legislation would require every state, except Nebraska, to 
     shoulder its fair share of the increased Medicaid costs the 
     bill will generate. The provision of the bill that relieves a 
     single state from this cost-sharing program appears to be not 
     only unrelated, but also antithetical to the legitimate 
     federal interests in the bill.
       The fundamental unfairness of H.R. 3590 may also give rise 
     to claims under the due process, equal protection, privileges 
     and immunities clauses and other provisions of the 
     Constitution. As a practical matter, the deal struck by the 
     United States Senate on the ``Nebraska Compromise'' is a 
     disadvantage to the citizens of 49 states. Every state's tax 
     dollars, except Nebraska's, will be devoted to cost-sharing 
     required by the bill, and will be therefore unavailable for 
     other essential state programs. Only the citizens of Nebraska 
     will be freed from this diminution in state resources for 
     critical state services. Since the only basis for the 
     Nebraska preference is arbitrary and unrelated to the 
     substance of the legislation, it is unlikely that the 
     difference would survive even minimal scrutiny.
       We ask that Congress delete the Nebraska provision from the 
     pending legislation, as we prefer to avoid litigation. 
     Because this provision has serious implications for the 
     country and the future of our nation's legislative process, 
     we urge you to take appropriate steps to protect the 
     Constitution and the rights of the citizens of our nation. We 
     believe this issue is readily resolved by removing the 
     provision in question from the bill, and we ask that you do 
     so.
       By singling out the particular provision relating to 
     special treatment of Nebraska, we do not suggest there are no 
     other legal or constitutional issues in the proposed health 
     care legislation.
       Please let us know if we can be of assistance as you 
     consider this matter.
           Sincerely,
       Henry McMaster, Attorney General, South Carolina; Rob 
     McKenna, Attorney General, Washington; Mike Cox, Attorney 
     General, Michigan; Greg Abbott, Attorney General, Texas; John 
     Suthers, Attorney General, Colorado; Troy King, Attorney 
     General, Alabama; Wayne Stenehjem, Attorney General, North 
     Dakota; Bill Mims, Attorney General, Virginia; Tom Corbett, 
     Attorney General, Pennsylvania; Mark Shurtleff, Attorney 
     General, Utah; Bill McCollum, Attorney General, Florida; 
     Lawrence Wasden, Attorney General, Idaho; Marty Jackley, 
     Attorney General, South Dakota.

  Mr. NADLER. Mr. Speaker, for seven years, the Republicans have tried 
and failed to repeal the Affordable Care Act. So now, with a 
Republican-controlled House, a Republican-controlled Senate, and a 
Republican in the White House, what have they presented us to vote on 
today? Republicans complained that premiums were skyrocketing, so they 
offer a bill that raises premiums. They complained that deductibles 
were too high, so they propose allowing insurance companies to charge 
more. They complained that too many people were losing their insurance, 
so they have embraced a plan that will take away health care from 24 
million Americans.
  This bill imposes a devastating age tax on older Americans and does 
next to nothing to protect Americans with pre-existing conditions. It 
gives nearly $900 billion in tax cuts to the insurance companies and 
the wealthy, while refusing coverage for services as basic as 
hospitalization. It's simple: Americans will pay more and get less 
under this bill.
  In New York, 2.7 million people will lose insurance and the state 
will lose $4.6 billion in Medicaid funding. Compounding those cuts is a 
cynical so-called deal several upstate Members made to secure their 
votes on this bill. Under the bill, New York State, and ONLY New York 
State, will no longer be allowed to ask counties to provide a portion 
of state Medicaid funding.
  Don't be fooled--this is no deal at all for New York and will 
actually gut the State's Medicaid program, forcing hundreds of 
hospitals to close and rationing health care for millions of New 
Yorkers.
  But my colleagues who have traded their vote for this provision have 
made an empty bargain. This provision is flatly unconstitutional and 
will never be enacted. They are giving away health insurance for 
millions of New Yorkers for an empty promise.
  My Republican colleagues claim we need to pass this bill to give 
people ``freedom'' to buy health insurance. Let me tell you, freedom to 
buy health insurance and actually being able to afford health insurance 
are two very different things.
  They keep talking about ``access'' to health care. Access is not 
coverage. When they talk about access and freedom, they are conceding 
that this bill does nothing to ensure that Americans have affordable, 
comprehensive health insurance to cover them no matter what their 
health care needs are.
  The Republicans so clearly believe that Americans just need freedom 
to buy insurance, that when asked what a pregnant woman should do if 
her state no longer requires insurance companies to cover maternity 
care, OMB Director Mick Mulvaney said she can ``figure out a way to 
change the state [she] lives in.'' How callous are my Republican 
colleagues to believe that is a real option for Americans?
  This bill is a cowardly, cynical effort to lower taxes on the rich 
and dismantle Medicare and Medicaid as we know it. I urge my colleagues 
to oppose this bill.

  The SPEAKER pro tempore. Pursuant to clause 1(c) of rule XIX, further 
consideration of H.R. 1628 is postponed.

                          ____________________